Scary Neuro-Surgeons!

For as long as I can remember I've been obsessed with the workings of the human body (hence my career choice) and my favourite bit of anatomy has to be the brain! When I was training as a physio I loved anything to do with the brain and nervous system, and when I got the chance to do my final year elective placement with one of the UK's leading neuro-physio's I jumped at it.  My first job was at Salford Royal Hospitals NHS Trust - AKA Hope Hospital, the Neuro-surgical Centre of excellence for the North West of England and I purposefully selected my junior rotation posts so as to make the most of being in the presence of neuro experts so I could learn from them.  From the very beginning Neuro-rehab was a big part of what I did.  When I started working at the Christie Cancer Treatment Centre, I was able to tie my two passions together when I took up the post of Senior Neuro-oncology physio, a job that I loved every single second of.
Despite my love of everything 'brain-ey', I did find the neuro-surgical wards a scary place to be.  Of all the patients in the hospital, these were some of the most critically ill I would ever come across.  I learnt very quickly that the line between life and death is a very fine one. I also learnt that the phrase 'a fate worse than death' has real truth in it, when I think of some of the patients I have treated who have had massive brain injuries and have been left severely disabled and debilitated but alive.  I can remember the tangible fear of the junior doctors on the wards at rounds time as they waited for the Consultant Neuro-surgeon to arrive.  As a junior physio I remember being made to feel completely inadequate when discussing patients with neuro-surgical nurses who had years of experience in the field and probably could treat the chest of an acutely ill patient far better than I could.  If it was my night to be 'on call', I would actually pray that neuro-surgery wouldn't call me,  and if in the middle of the night the pager would bleep (before mobile phones!) and I'd see their extension number I'd almost get sick to my stomach.  I felt that neuro-surgeons where scary, egocentric genius's with a very definite God complex, but I've always been intrigued by them and I suppose in awe of them,and in 2007, when a neuro-surgeon saved my mothers life, that particular surgeon got elevated to 'Legend' status!  So when I recently came across Consultant Neuro-surgeon Mr Henry Marsh's book 'Do No Harm', I had to read it.  And I am so glad I did. It gives a fascinating insight not just into the world of neuro-surgery, it also reveals the humanity behind that 'scary' façade  - a humanity which enables them to perform what must arguably be the most difficult and risky surgical procedures for the good of their patients.  They have to have the God complex, they have to believe that they are the best because if they make a mistake someone dies or worse can suffer a 'fate worse than death'.  Please God, I never have to go under the knife of a neuro-surgeon, but if I did I want him or her to be the scariest, most egoncentric genius I have ever met.  I'd highly recommend the book!

Lipoedema Case Study

I have recently been treating a client with intensive decongestive lymphatic therapy (DLT) who has lipoedema.  The lady is 37 years of age.  Her history and examination reveals that she ticks a lot of lipoedema boxes:

• bilateral symmetrical 'big' legs, disproportionate for waist/trunk size
• history of bruising easily
• endless attempts to lose weight and when she has lost weight it hasn't gone from the legs
• 'orange peel' effect on the legs
• feet are not affected and look 'skinny' in comparison to her ankles
• non-specific achy feelings and heaviness in the legs
• strong family history of thyroid disorders
• other female relatives have similar big legs
• her legs were overly tender to light pressure
• her symptoms were exacerbated during pregnancy

The photo below shows her pre and post Delfin Moisture Metre readings along with her limb volumes. 

This is an ongoing case, I am still seeing this lady, the above post measurements are taken on day 5 of treatment. 

Subjectively the lady is feeling immense benefits from the treatment.  She says that her legs feel so much lighter than they have ever done, she doesn't have the aches and soreness that she was so used to and she is loving the fact that she herself can see her "ankle bones" and has shape in her calves.  

I sincerely hope that we can maintain these improvements as we continue to work together.  

I am plagued by questions as to what was/is going on in her legs based on the objective findings and putting that together with the knowledge I have gained during my recent Fluoroscopy Guided Manual Lymphatic Drainage (FG-MLD) training.  And I am specifically looking at area 'A' in the diagram.  On initial assessment there was definitely higher Moisture Metre readings in that are in her left leg. The left:right ratio difference in area A is averaging 1.3.  Her left leg did have a slightly higher volume and after 5 days had a reduction of 1370mls when compared to 805mls on the right.  But what interested me more is that the Moisture Meter readings were very much reduced on the left and more equal to those on the right - leading me to conclude that we had gotten rid of the excess fluid in that area.  But I then ask why was there more fluid just in that specific area?????? On assessing women with very early stage lipoedema, this area typically is where we can palpate the rubbery fat nodules, and is commonly an area that ladies identify as where they can see the abnormal fat in their legs.
So, when I think about what I learnt in my FG-MLD training recently - commonly there is an area just below the knee - roughly around area 'A' where we find our 'fill' spots.......I don't know where this is going but I am sure there is a research question in there somewhere, I just don't know what it is.  

I would love to get other therapists views on this - any thoughts?????

Lipoedema

Recently I gave a talk on Lipoedema explaining what it is, how it is diagnosed and how it is treated and managed.  Here is the slide show, a lot of it is self explanatory but I'm happy to answer any questions if you comment below.

FG-MLD....challenging and changing what we know about lymphoedema!

I've just spent the weekend in Cork doing some training with Jane Wigg of The Lymphoedema Training Academy, learning all about the new Fluoroscopy Guided Manual Lymphatic Drainage (FG-MLD) technique. I first did my MLD training with Jane in 2009 and ever since have been using it to great effect with clients who present with lymphoedema and chronic swelling. There is no doubt in my mind that MLD works – we know that, we see limbs shrink in volume, we feel fibrosis soften and we hear what difference that is making to patients. There are different schools of MLD, all using slightly different techniques but with broadly similar treatment aims – to re-educate the lymphatic system to take fluid away from where it is collecting to an area where it can be drained effectively. A problem that we have though in the field of MLD is that up until very recently, we didn't know for sure exactly how it works and the 'it just does' view has little value in the inquisitive and evidence based medical world. There is very little published research evidence available to prove that MLD works. We can set our hypotheses but actually testing them at the most vigorous level is difficult. So my mind has been well and truly blown over the last few days when I have learnt about some of the most recent work being done in lymphology to strengthen the evidence base and to finally answer with conviction the 'how it works' question. Professor Jean Paul Belgrado's work using an infrared camera to view the lymphatic system in living people is further building on Professor Leduc's anatomical work on cadavers from the 1970's. The evidence is compelling. Now we can see lymphatic flow in action in real life, we can see the impact that a compromised lymphatic system is having on that flow and we can see exactly how our hand placements, stroke movements and pressures applied can be adapted to maximise the effectiveness of the MLD technique, and that is what Jane Wigg, Professor Belgrado and his team have done with the creation of FG-MLD. I actually think that this new knowledge will have a massive impact on how we manage lymphoedema now and in the future and in my mind it is a significant medical breakthrough that will have life-changing consequences. Think about how Watson and Crick impacted on our knowledge of genetics or Fleming contributed to fighting infection – I think FG-MLD is the double helix or the penicillin of today!

So, what does this mean to MLD Therapists who are currently effectively treating people with lymphoedema using MLD techniques that have been tried and tested over decades, what does FG-MLD offer us? Well, it means we can have a fuller more informed understanding of what we are doing and why, and have the conviction to be able to say 'This works and we have the evidence to prove it'. It means that we can achieve more, we can have even better outcomes we can be even more effective at moving fluid and softening fibrosis. For patients with lymphoedema it means we can provide you with a researched and evidenced based technique which will reduce your swelling and it will improve your quality of life.

As a therapist I find this incredibly exciting and as I said 'mind-blowing', although at the same time I find myself really challenged. Challenged to change what I am doing, challenged to think differently, challenged to accept a fundamental change in the approach and underlying assumptions to that which we heretofore held about lymphoedema and MLD, challenged to trust this paradigm shift. How comfortable am I with such a high level of challenge? To answer that I have to bring my focus back to why I do what I do. I am a clinician, I want to achieve the best for my clients, I want to make them better, yes the techniques that I am currently using are doing that, but if I can use something that promises to be even better........I can't erase the images in my mind of the fluorescent lymphatic fluid being pushed out of a limb that are there since I saw the video evidence over the weekend. For me its a no-brainer! It's FG-MLD all the way from now on!

So, I actually can't wait to bring this knowledge to my clients. I can't wait to tell them all the new stuff I've learnt (and tell them to forget some of the stuff that I would have told them previously) and I CAN NOT wait to try out the new technique and see the results for myself . The world is revolving and evolving at a fast pace and similarly we have to evolve in our clinical practice. I for one am delighted to be part of this exciting new world of lymphoedema management!

Lymphoedema........is it OK to get a massage?

I'm often asked about getting a massage by people who have lymphoedema or may be at risk of developing it due to treatment over a lymph node area.  The answer to this is not a simple 'Yes' or 'No'.....more of a 'well, you can and you can't' (typical Irish way of answering a question I know!).  So here's my guide to the things to think about...
Most important  - is the person offering the massage qualified to do so, and what are their qualifications.  If you are paying for a massage (as opposed to a family member, partner or friend providing it) then you do need to check out what training they have done.  Gold standard would be they are trained in the lymphatic system by one of the recognised schools of Manual Lymphatic Drainage (Leduc, Foeldi, Vodder, Casley-Smith and the Lymphoedema Training Academy - this is the one I do my training with!).  Any therapist with this training should have a full appreciation of the lymphatic system and what can cause lymphoedema or make it worse and therefore you should be in safe enough hands getting massage from them (it'll probably very likely be an MLD type treatment anyway - which is the best thing for the lymphatics).
There are however many massage therapists available that do not have the above training, and I think I am right in saying that the majority of therapists who work in Spa's, beauty clinics, hotels and sports facilities etc would fall in to this category. So similarly ask them what training they have done in the lymphatic system.  I would tell them that I either have or am at risk of developing lymphoedema and ask them how that would impact on the massage.  I'd then judge by their response would I go ahead with the massage - so I would be looking for them to explain to me how in this situation massage needs to be gentle and that all deep heavy strokes need to be avoided.  I would also be looking for them to ask me for more information in order for them to make a full assessment of me and then to be able to deliver the most appropriate massage for me.  I would have to be assured that I knew that they knew about lymphoedema - if I feel that then grand, if there was any doubts in my mind I wouldn't go ahead.

Strong deep strokes around the part of the body where the lymph nodes are compromised is not recommended. So if it's your armpit that is affected, avoid deep massage in the associated arm, breast, chest and back area.   Massage in that area should be light and gentle and strokes should always go towards the centre of the trunk.  I would strongly advise against getting a 'cupping' massage - where heated glass cups are placed on the body and as they cool they create suction which apparently 'stimulates circulation and healing', think 'lovebite' - cos that's what you end up with -  a series of big dark bruises wherever the suction was applied.  Physiologically a bruise is a sign that tissue damage has occurred, whether it be from getting a bang off a piece of furniture or from a 'healing treatment'.  If your impaired lymphatic system cannot cope with the demand that the increased circulatory and inflammatory response to this 'therapy' will place on it then you could run into trouble.
After having cancer treatment you may find your skin a little more sensitive than it was before.  You might need to avoid the use of perfumed creams and lotions.  If getting an aromatherapy massage, be sure to tell the therapist that you have had/having treatment and they can select the most appropriate oil for you.
Ask around - word of mouth is often the best way of finding the best people.  There are some very good massage therapists around who I would happily refer any of my clients to and if anyone wants their details then let me know.
There are immense benefits of receiving massage therapy by a trained competent therapist who can work with you tissues to bring about relaxation and release of tension throughout the whole body, and this can be very healing in itself, both physically and psychologically.  It is so important if you have/are at risk of getting lymphoedema to make sure you take all precautions that you need to take.  It is YOUR body, and you have to give permission to someone to place their hands on your body - only do that if you are completely happy they know what they are doing because at the end of the day, if something does go wrong, it is you that has to then deal with it.  You need to do your own risk assessment.  Unfortunately I have seen many clients who have received 'massage' and then end up coming to me because lymphoedema symptoms have been exacerbated. On questioning all these clients have said that they didn't feel totally convinced or comfortable that the therapist knew about lymphoedema, despite the fact that they might have said they did.
In the Autumn I will be running a course aimed specifically at body work in clients that have had breast cancer.  This will be open to any touch therapist (massage, physio etc) who might encounter breast cancer survivors in their work. We will be exploding some of the myths and exploring the many possibilities and benefits available from working on the body tissues through therapeutic touch.  More details will be posted soon, or contact me for more info.

My top tips for new Physiotherapists

There's a busy conversation on the Twitter machine at the moment #toptipsfornewphysios - quite timely as now is the time of year that new grads are starting out in the big bad world of work.  So, I decided that 18 years after I was in that very same exciting but daunting situation, here are some of the pearls of wisdom I have collected over the years:

1. It is important to make a personal connection with the patient/client.  Always introduce yourself #hellomynameis and never assume that the name you see on the referral letter or medical chart is the name the person likes to be called.  Always ask the person how they would like to be addressed - 'Is it OK for me to call you......?' or 'what would you like me to call you?'  
2. Make the most of non-verbal communication - 3/4 of the stuff we communicate is done through non-verbal communication - how we appear to the patient.  Be very aware of this! How you stand, hold your arms, even how you are dressed will send out very powerful messages - you want to make sure you are sending out the right ones.  Be wholly attentive to the patient, get yourself at eye level, use open arm gestures and relaxed postures to encourage an environment that is conducive to the sharing of information (so important in your history taking!)
3. Always remember that we treat PEOPLE not tissues or conditions or injuries.  OK, so we do do a fair bit with tissues and injuries - that's physio, but behind every injury is a person - you'll be a better physio if you never lose sight of this. 
4. Use your own internal quality gauge when going about your work - some simple questions to ask yourself - 'Would I be happy if roles were reversed here and I was the patient and 'they' where the physio?', 'Would I be happy if my Dad/Mam/Sister/Brother/Grandma/Grandad received physio treatment like that?', 'What would I want?'........If you're happy with the service you are providing then great, if not then do something about it! 
5. If you're going to work in the NHS/HSE you will undoubtedly encounter the political stresses and strains of the system that will impact on your work.  Get yourself some advanced communication/conflict management/industrial relations training - the type of thing that comes with training as a Union Rep - when I trained as a CSP Rep years ago, my eyes were opened to exactly how the healthcare system works, and more importantly it enabled me to appreciate the complexities of the healthcare hierarchy and the personnel relationships within it - Hopefully you will have a long career in the health service, and having this knowledge will make it easier for you to contribute to strategic planning and the improvement of services and it might just prevent yourself from banging your head against a wall!!
6. If you can, get some experience working in a specialist oncology setting  with specialist oncology physios.  #cancerrehab is such an exciting area to be working in right now (it had me hooked 16 years ago!).  There is a massive amount of research coming out about the effects and impact of exercise and physical activity for preventing cancer, reducing recurrence, making treatments more effective and improving patient outcomes.........We are definitely on the crest of a very big wave and once it hits, then patients, doctors etc are going to be looking more to the exercise specialists to intervene in cancer treatment.....and that's us!!!!!
7. Do some Manual Lymphatic Drainage training.  I'm not sure if physio course itineraries have changed much since the early 90's, but I remember very little, almost non-existent teaching on the lymphatic system (apart from it being something to do with the immune system - killer T-cells, remember them!).  BUT, the lymphatic system is one of the most important systems in the body and and appreciation of how it interacts with all of the other systems and how it is involved with injury, healing, repair and nourishment of tissues will add vital information to your clinical evaluation, reasoning and treatments.  I wish I had done my MLD training years earlier than I did, I use it all the time, not just with lymphoedema and swelling. 
8. If you make a mistake or do something wrong then apologise  and learn from it - simple! 
9. The day that you think you don't need to learn anymore, or even worse, the day when you think you don't care anymore - GIVE IT UP AND GO ON GARDENING LEAVE!!!!!!!!!!
10. ENJOY every second, learn from every experience, keep an open mind, smile and laugh, be creative and have fun, reflect often, mind yourself, grow personally and professionally.  Always appreciate that you are in a great profession - you have the skills to massively impact on other peoples health and wellbeing, you meet amazing people daily, and no 2 days are the same .......... and before you know it you will be an 'old' physio (but in your mind you're still a fresh faced new grad with the whole world to learn) and you'll wonder to yourself 'How the hell did that happen?!?!?!?'  

Don't miss YOUR chance to shape the future of cancer services in Ireland!!

I posted on Facebook recently about how the Department of Health here in Ireland have appointed a steering group to work on a National Cancer Strategy for 2016-2025.  The work hasn't yet started - there is a period of public consultation whereby the public (we and us) are able to make comments to the Department of Health and steering group (them) regarding our own views/opinions/experiences of cancer care in the country and how we think things should proceed. Now, this is a really important opportunity for 'us' to impact on what goes into that strategy document, we shouldn't waste this chance.  Having worked on a similar level of national document in the NHS (NICE Improving Outcomes for Brain and Spinal Tumours) in the past, I can tell you that each and every comment that comes in through the public consultation period is read, recorded and acknowledged. So lets imagine that we wanted an improvement in access to specialist cancer rehabilitation services - you know to help people get their life back on track once medical treatment has done its stuff. If only one member of the public mentions this in their feedback form, you could see how it would be easy for 'them' to assume that access to rehab services isn't really an issue, as only one person has brought it up......but if a hundred people mention that they are very concerned about lack of access to specialist cancer rehab, then it would be a little harder for the Steering Group to ignore this!!  I'm not trying to tell you what to include when you give your comments - there are many areas of cancer care that could be improved upon, but naturally as a physio working in this area this is one of my major concerns, along with the nearly non-existent provision for lymphoedema services. And just to put this into a bit of context - The National Cancer Strategy Document that was published in 2006 contains the words 'lymphoedema', 'lymphedema' (American spelling), 'physiotherapy' and 'rehabilitation' a grand total of ZERO times........can you imagine that - a strategy for cancer care that doesn't even contain those words which are so vital to the complete package of care offered to anyone having cancer treatment.
This is now 2015.  We have shed loads of research which support physiotherapy and rehabilitation as a key aspect of cancer care not to mention the countless models of comprehensive care around the globe where these things are already part and parcel of what is on offer.  Lymphoedema occurs in upto half of all patients who have some form of treatment to their lymph nodes - it is a BIG part of cancer care and it does need to be mentioned.   If 'they' get lots of comments via the public consultation process asking what they are planning to do to make sure that everyone who needs lymphoedema services is able to access them, or everyone that needs physio is able to access it as part of their total cancer management then they will have to address this and come up with a really good reason if these things are not contained in the document.    So please when you see the link is taking you to the DoH website, don't groan and think to yourself 'what's the point'......CLICK the link. It's here again for you (and you do have to click on the blue word 'here' on that page to access the document) and fill out the form.  Collectively our voice can be very LOUD!