Accurately assessing and diagnosing hip and groin pain is a very difficult matter. This is, in no small part to the sheer number of structures which intersect this area. Dr. Franklyn-Miller introduces the “pubic clock” (see below) as an assessment aid for such issues. The clock clearly depicts each area of the hip and groin that needs to be assessed with these patients. To get the benefit of the pubic clock, locate the pubic symphysis on the painful side, from here use the clock to locate the source of pain (superior, inferior, medially or laterally).

Groin-3.-The-Pubic-clock-1024x736

Dr. Frankly-Miller also uses what is called the groin triangle to aid his assessments. The groin triangle is made up of the anterior superior iliac spine (ASIS) (superior point), the pubic tubercle (medial point) and what is known as the 3G point. The 3G point is the mid distance between the ASIS and the superior pole of the patella anteriorly. In the posterior coronal plane the 3G point is double the distance from the spinous process of L5 lumbar vertebrae to the ischial tuberosity in the line of the femur.

2013112684716

For a more in-depth understanding of the groin triangle and the anatomy of each border and point, see the below article published by Dr. Frankly-Miller in 2011. Also outlined within this article is further detail regarding the above mentioned pubic clock.

http://www.rehabroom.co.uk/resources/Groin%20Pubic%20Clock.pdf

Whiplash can be defined as an “acceleration-deceleration mechanism of energy transfer to the neck. It may result from …motor vehicle accidents… The impact may result in bony or soft tissue injuries – whiplash injury, which in turn may lead to a variety of clinical manifestations – whiplash associated disorders” (MAA, 2014).

This definition arises from the Quebec Task Force (QTF), a group who were sponsored from a public insurer in Canada who developed a guide for managing whiplash in 1995 (Physiopedia, n.d.) – several updated versions have since been published. The QTF focused on clinical issues, specifically risk, diagnosis, prognosis and treatment of whiplash and these guidelines were largely developed by consensus and the expert knowledge of members of the QTF (MAA, 2014).

To assist in the diagnosis of WAD, the QTFC (Quebec Task Force Classification) was introduced by the QTF. It indicated 5 grades of WAD (grade 0 through to grade 5), with each grade corresponding to a treatment recommendation. However, some have questioned the usefulness of the QTFC, as evidence demonstrated differences in physical and psychological impairments between individuals who recovered fully from a WAD, compared to those who were left with chronic pain and disability (Sterling, 2004).

As a result, Sterling (2004) introduced a modified QTFC as per the below –

Proposed classification grade

Physical and psychological impairments present

WAD 0 No complaints about neck painNo physical signs
WAD I No complaints of pain, stiffness or tenderness onlyNo physical signs
WAD IIA Motor impairment

  • decreased ROM
  • altered muscle recruitment patterns (CCFT)

Sensory Impairment

  • local cervical mechanical hyperalgesia
WAD IIB Motor impairment

  • decreased ROM
  • altered muscle recruitment patterns (CCFT)

Sensory Impairment

  • local cervical mechanical hyperalgesia

Psychological impairment

  • elevated psychological distress (GHQ, TAMPA)
WAD IIC Motor impairment

  • decreased ROM
  • altered muscle recruitment patterns (CCFT)
  • increased JPE

Sensory Impairment

  • local cervical mechanical hyperalgesia
  • generalized sensory hypersensitivity (mechanical, thermal, ULNT)
  • Some may show SNS disturbances

Psychological impairment

  • elevated psychological distress (GHQ, TAMPA)
  • elevated levels of acute posttraumatic stress (IES)
WAD III Motor impairment

  • decreased ROM
  • altered muscle recruitment patterns (CCFT)
  • increased JPE

Sensory Impairment

  • local cervical mechanical hyperalgesia
  • generalized sensory hypersensitivity (mechanical, thermal, ULNT)
  • Some may show SNS disturbances

Neurological signs of conduction loss including:

  • decrease or absent deep tendon reflexes
  • muscle weakness
  • sensory deficits

Psychological impairment

  • elevated psychological distress (GHQ, TAMPA)
  • elevated levels of acute posttraumatic stress (IES)
WAD IV Neck complaintFracture or dislocation

 

Furthermore a useful algorithm, known as the Canadian C-Spine Rule (CCR) was adapted by Stiell et al. (2003), to indicate whether radiography is indicated in those who may present with cervical spine injury and trauma (perhaps not only from motor vehicle collision)…

 

Canadian C-Spine Rule

Both the MQTFC and the CCR are standardised and well evidenced ways of ensuring good and accurate assessment and diagnosis of varying degrees of whiplash, given the amount of variables that can contribute to a variety of WAD. It also ensures good practice in the communication of such diagnoses between healthcare providers during a referral pathway.

Follow the links in the references below for further reading…

References

Motor Accidents Authority (2014) Guidelines for the management of acute whiplash associated disorders for health professionals 2014, 3rd edition, accessed online 06/02/2015  https://www.maa.nsw.gov.au/__data/assets/pdf_file/0011/18956/Final-Guidelines-for-the-management-of-a~d-WAD-disorders-for-health-professionals-3rd-edition-2014-MAA32-0914-28-11-14a.pdf

Physiopedia (n.d.) Whiplash Associated Disorder, accessed online 6/2/1015 – http://www.physio-pedia.com/Whiplash_Associated_Disorders

Sterlin M (2004) A proposed new classification system for whiplash associated disorders—implications for assessment and management, Manual Therapy, vol 9 (2): 60-70.

Stiell IG, Clement CM, McKnight RD, Brison R, Schull MJ et al., (2003) The Canadian c-spine rule versus the NEXUS low-risk criteria in patients with trauma, New England Journal of Medicine, vol 349 (26): 2510-2518.

 

The Hunter Intergrated Pain Service, based in Australia, provides an excellent insight into the link between primary care settings and specialist pain management services.

This short, but very effective video highlights key factors surrounding pain management. Its focusses upon the deep-rooted, multifactorial issues that ultimately sustain ‘chronic’ pain, long after initial injury and/or trauma has occurred and indeed, settled.

Providing a brief educational video in this manner benefits both patients and clinicians; key messages surrounding the complex issues of chronic pain are addressed in a concise and clear manner, whilst this can also be utilised as an innovative tool during patient consultations, to be displayed in the waiting room, etc.

Click here for a link to this video.

Reference: Hunter Integrated Pain Service (HIPS) Fast track Pain management in Primary Care, accessed 24/01/2014, at http://www.archi.net.au/resources/primary/partners/fast-track-pain

 

 

The Chartered Society of Physiotherapy (CSP) recognises that improving the quality of healthcare is high on the agenda within the UK . Standardised and validated clinical outcome measures are one way of gauging the service delivery, quality of patient care provision and the quality of clinical practice within the NHS.

Orthopaedic Scores is a highly useful website that collates an array of orthopaedic outcome measures all under one roof.

Outcome measures are available to be accessed by both patients and clinicians, can be saved electronically or printed as hardcopies and are entirely confidential.

Examples include the KOOS (Knee injury and Osteoarthritis Outcome Score), the DASH (Disabilities of Arm, Shoulder and Hand) and the Oswestry Low Back Pain score.

Used correctly, outcome measures offer the ability to highlight if a patients orthopaedic complaint is being managed well, or indeed, if it is not, whilst also offering substantiated, valid evidence that can compliment an onward referral to our orthopaedic colleagues.

Click here for a link through the Orthopaedic Score homepage

The Keele STarT Back Screening Tool (SBST) is a new tool that has been developed for patients with persistent Low Back Pain (LBP). It allows for prognostic screening to help aid overall treatment and management pathways in a primary care setting.

The SBST helps to categorise patients into 1 of 3 ‘risk of poor outcome ‘groups; low, medium or high. Each group then carries a different intervention pathway that can be implemented, depending on the patients answers to a set of standardised questions.

A recent trial of the tool published in The Lancet indicated a cost saving approach. The tool itself was funded by Arthritis Research UK and the results of a recent Randomised Control Trial (RCT) of the tool are pending publication… Watch this space!

The original SBST screening tool can also be adapted into a numerical rating scale and can be used during their management to objectively measure how patients are responding to treatment.

Click here to be taken through to the Keele STarT Back Screening Tool website for further reading and how to use the SBST.

Click here to be taken directly to online version of the SBST.

 

Cawthorne Cooksey exercises were one of the initial regimes developed to assist in the recovery of vestibular problems. Although considered outdated, they are still commonly utilised today and do not require hands on treatment from a clinician.

Cawthorn Cooksey exercises attempt to rehabilitate the inner ear by repetitively performing movements of the head to reduce the amount dizziness provoked by such movements, together with traing the movement of the eyes independant of the hand and loosen up protective muscle spasm from the musces in the head and neck. These exercises are adapted from Dix and Hood (1984)

Click on the following link for a step by step guide to CawthorneCookseyExercises

Note: Ideally, these exercises should not be performed completely alone. Discussion with a clinician first is important as ultimately every individual is different, whilst performing the exercises with a family member/relative is advised.

 

The Association of Chartered Physiotherapists in Women’s health (ACPWH) have recently published a leaflet regarding pregnancy related Pelvic Girdle Pain (PGP), formerly known as Symphasis Pubic Dysfunction (SPD).

This leaflet has been peer reviewed by an MDT and draws upon an evidence base, expert opinion and patient’s own experiences, thus providing a well rounded informative guide.

This includes information regarding diagnosis, a referral and care pathway and ante-natal guidance, as well as post-natal care on the ward and after discharge, with plenty of tips that can be passes onto patients directly.

Follow this link to the leaflet – Pregnancy related Pelvic Girdle Pain

 

A  recent study conducted by colleagues at Warwick university has concluded that a package of physiotherapy sessions are not cost-effective for the NHS, despite showing that a modest recovery can be made in the early symptoms of whiplash.

A further article in The Lancet raises the question as to why whiplash is treated with such serious connotations within the healthcare environment.

Click here for a link to the Chartered Society of Physiotherapy’s website for further reading.

Click here for a link to the study itself, published in The Lancet.

 

Due to popular demand, clinical information and exercises for Medial Epicondylitis /Golfer’s Elbow now available.

 

http://www.csp.org.uk/news/2012/01/30/advice-issued-over-hip-replacement-conerns

 

http://www.csp.org.uk/frontline/article/physio-findings-shoulder-pain

 

Our New Website

May 19th, 2012

Our new website went live on 1st October 2012.  We hope you find it helpful and informative.  We’d welcome your feedback on any aspect of the site.