julia_tabrah
@julia_tabrah
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Consultant Physio, NHSE MSK Lead for London, Clinical Integration Lead and Advanced Practice Lead.
Joined November 2016
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New head & neck red flag screening tool.
Co-created with Roger Kerry, Alan Taylor, Firas Mourad, Helena Bridge, David Herdman.
Aide memoire not a triage tool.
Feedback welcomed 🙂
#redflags
#cancer
#stroke
#dcm
#Headache
@RogerKerry1
@alantaylor1
@DrFirasMourad
@HRCH_NHS
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New Spinal Red Flags Resource created with Dr. Yvonne Harrington. Covers key red flags for the Big 6 with links to more info. Aimed at GPs but may be useful for others. Hoping this will aid early detection.
Please share with your GP colleagues. Feedback welcome as always :)
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Myself and a colleague created this simple credit card to help us remember the basic cranial nerve tests. Please feel free to use, share and feedback your thoughts. Hope its useful. Thanks :)
#cranialnerves
#neuroexam
#cervicovascularscreening
#triage
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Back pain is not always non-specific.
Remember to screen for cauda equina, radiculopathy, AAA, kidney, AxSpA, myelopathy, cancer, infection, fracture, hip/pelvic pathology, unstable spondylolisthesis, DISH, etc.
Any others?
#multisystemsclinicalreasoning
#backpain
#triage
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Free myelopathy training resource
We delivered this training to GPs and physios. All participants reported a significant increase in awareness and triage confidence.
Presenting the results at BritSpine next week. Slide decks below - pls use and share :)
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What are the early, middle and late stage symptoms of degenerative cervical myelopathy (DCM)? We used a 2 stage survey and expert consensus meeting with 12 physios and neurosurgeons. Hoping to present at BritSpine in April, but here is a preview. More research needed...
#hrch
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Degenerative cervical myelopathy education video - hot off the press!
This 24 minute video gives you all the need-to-know information about DCM. Designed for all clinicians of all backgrounds. Please share to help reduce diagnostic delay
@myelopathyorg
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Love this NICE suspected cancer infographic:
Very useful, but we must also remember to trust our instincts...most text book red flags are 'end stage'. If it doesn't feel right...image!
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Myelopathy is more common than you think.
Degenerative cervical myelopathy is the most common type.
All the key info about DCM assessment/diagnosis/triage is here in these slides:
1 in 50 adults are estimated to be affected by DCM. This rises to 1 in 20 over the age of 50
#Research
#Studies
#OneinFifty
#MyelopathyResearch
#Myelopathy
#MyelopathyMatters
#MyelopathyCharity
#MyelopathyAwareness
#MyelopathySupport
#CervicalMyelopathy
#MakingMyelopathyMatter
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MSK Suspected Cancer pathway updated
Please feel free to adapt to your local MSK Triage service
Needs to be agreed locally and unwelcome news training is essential
@thecsp
@NatSpineNetwork
@APPN_physio
#cancer
#physio
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***New spinal fracture pathway***
Co-created with
@_AndrewMcCarter
and the London Spine networks
Builds on the great work already done by
#BestMSK
Osteoporotic, traumatic and pathological fractures all on one page
Adapt to your local service
Feedback welcomed 🙂
#hrch
#kch
@julia_tabrah
and I have developed a London Spinal Fracture Pathway. Feedback from the five London Spine networks have been incorporated and it is now ready to launch. It is designed to be adapted to your local service, alongside your key stakeholders. Please DM for PDF version.
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Awesome lecture by Giovanni Ferreira at
#BritSpine2023
on diagnostic labels for LBP
1. Take care with language
2. There is no one size fits all explanation - tailor to the individual
3. Let's spread the message to all clinicians including primary care
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@ashjamesphysio
will the CSP be responding to this article in the Daily Mail? Happy to help if I can
We need to set the record straight but we also need to reflect on how the public view us and what we can do to prevent people feeling fobbed off
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Hot off the press - DCM SR on clinical signs :)
* Tromner and hyper-reflexia most sensitive
* Babinski, clonus, Tromner, inverted supinator most specific
* Consider imaging if +ve tests
* Don’t be reassured by normal tests if strong DCM history
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Spinal mets and MSCC - updated NICE guidance….
If suspecting mets contact MSCC coordinator with 24 hours and MRI within 1 week- depends on local pathways who will action this.
If suspecting MSCC contact MSCC coordinator immediately.
More info here:
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GP and Physio versions available on this link:
Myelopathy is more common than you think.
Degenerative cervical myelopathy is the most common type.
All the key info about DCM assessment/diagnosis/triage is here in these slides:
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Currently leading an expert consensus project to try and map the early, middle and late stage symptoms of degenerative cervical myelopathy (DCM). Hoping to identify the more subtle early symptoms so that we can catch DCM sooner and close the diagnostic gap. Watch this space :)
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PR of anal tone no longer recommended for cauda equina assessment/diagnosis
#bass
#sbns
#csp
#appn
#bestMSKhealth
#consultantphysio
#hee
#rcr
#rcem
#rcgp
#msksp
Can digital rectal examination be used to detect cauda equina compression?
@julia_tabrah
explains the findings of her team's systematic review on the topic in this 9min video:
Article here:
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@thomas_jesson
Great reminder, thanks Tom.
In case it's useful I remember the meds like this:
GabaLeak - AmiRetain
Gabapebtin can cause bladder leakage/incontince
Amitriptyline can cause retention
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Ingrid Hoeritzeur giving a great talk on scan negative CES and functional neurological disorder
@BritSpine2023
See here for a summary of FND examination:
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Here is my BritSpine DCM presentation for anyone whose interested - 3rd speaker. Wearing a beach dress and children's shoes because BA lost my suitcase. Grrrrr.
Hope it's useful:
#dcm
#research
#CPD
#hounslowandrichmondcommunitytrust
#BritSpine2023
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Awesome 5 minute video on differentiating between sciatica and vascular pain by
@TaylorAlanJ
Summary: vascular pain more likely to be non-dermatomal, exercise induced pain, possibly wrapping around the limb in a band, with or without non- myotomal weakness
Vascular flow limitations of the lower limb ... how do I differentiate from 'sciatica'?
A short educational VIDEO for clinicians
#ClinicalReasoning
#Vascular
#Physiotherapy
#PhysicalTherapy
#Atherosclerosis
#Endofibrosis
#Pain
#ReferredPain
#sciatica
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No DCM symptoms are diagnostic in isolation
Many other symptoms exist but don't occur at a consistent stage in the condition
Planning a larger formal expert consensus project with lived experience to gain a deeper understanding of symptom chronology
Scan or refer if concerned
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Excited to present our systematic review at PhysioUK tomorrow, summarising the evidence on reliability of digital rectal exam for detecting cauda equina compression.
#lowdiagnosticaccuracy
#falsereassurance
#earlydetectioniscritical
#physiotherapy
#vpuk2021
#FCP
#APPN
#CPD
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Ask yourself:
1. Do you over scan? Are you willing to run late to explain why they don't need a scan?
2. Do you under scan? Do you listen out for the more subtle 'early stage' red flags, believe what they tell you and trust your instincts?
The truth is somewhere in the middle
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@f_diffley
@thomas_jesson
@Mercephysio
@adamdobson123
@michangus
@DrJN_SportsMed
@ClementsCharl96
Currently working on a cervical red flags resource with Alan Taylor, Roger Kerry, Nathan Hutting and Firas Mourad. Watch this space. Also just completed 2 myelopathy research projects which I am hoping to present at BritSpine. Will post results on here when I get a minute spare
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Loved attending the HoP for an all party parliamentary group meeting on Axial Spondyloarthritis.
Discussed tackling diagnostic delay with undergrad training and getting funding agreed with cost avoidance business cases
@NatSpineNetwork
#NASS
#AxSpA
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Cauda equina compression (CEC) = cauda equina symptoms + marked canal stenosis on MRI
You need the symptoms and the stenosis for a diagnosis of cauda equina compression.
Should the RCR therefore discourage radiologists from describing CEC on a scan alone?
Discuss ☺️
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@DerekGriffin86
Totally agree Derek that unnecessary tests are harmful. But we also need to bear in mind that most red flags are end stage symptoms of serious pathology. Most people with back pain don't need an MRI, but if you get a gut feeling that something isn't right: scan or refer.
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Really interesting: OA now thought to be caused by metabolic conditions, obesity, lipid abnormalities and genetics, as well as wear/tear, cumulative force and injury. Maybe we should advise diabetics that managing their diabetes better might improve the health of their joints??
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Spinal fracture pathway updated in response to feedback and editable version now available. See link below.
Please feel free to share, download and adapt to your local service ☺️
**Click link for updated, downloadable, and editable Spinal fracture pathway template.
In response to feedback received we have added 'consideration of baseline bloods and myeloma screen' to the left hand side of the page.
@julia_tabrah
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Loved meeting John Cowman, new CSP Chief Exec this week. Such a nice guy. Generously shared his expertise on leading through complex change. Discussed
#hierarchy
,
#protectionism
,
#fearofchange
and creating a
#positiveworkplaceculture
.
Thank you John :)
@JPCowman
@thecsp
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I'm getting a bit fed up of the media causing health hysteria by turning every virus or ailment into a potential pandemic that will kill us all. It's exhausting and it's clogging up our EDs.
Does the UK government need to employ someone to oversee health messaging in the media?
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Surprised to say that I feel a bit emotional today.
So proud to have worked for the NHS for 25 years.
We have have come so far and achieved so much, but there is still a lot to do.
Happy birthday NHS!
#75
🎈
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@Retlouping
Totally agree. So many posts have a sarcastic or derisory tone. It makes our profession look immature and bitchy.
We are all learning. Every day's a school day. If someone gets it wrong, let's steer them back on track, not ridicule them.
Thanks for raising 👍
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Great to hear about the progress of the
#BestMSKHealth
collaboration. Raising the profile of MSK health and taking us closer to an integrated, collaborative, best practice approach ☺️
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@Retlouping
I agree that we should avoid imaging people with mechanical MSK pain where it won't change management and can cause anxiety when it shows normal abnormalities. But that is a very seperate conversation. We need to make the message clear. If you are worried....image or refer. Now.
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@adamdobson123
If there is no suspicion of serious pathology, AxSpA or neurological deficit, then it is rarely appropriate to scan regardless of where you sit in the pathway anyway right? Sorry, am I missing something?
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@ClementsCharl96
Thanks Charlie
IME they rarely describe a pop and they don't always have a severe kyphosis.
Great that you are trying to map this out, but I think you might have slightly over simplified it.
I am currently working on a spinal fracture pathway and it's 3 pages long!
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@adamdobson123
I think wear and tear is ok for some people (if explained well) and absolutely not ok for others.
Some people find age related change a bit pompous and osteoarthritis a bit scary.
There is no perfect term. We have to tailor the language to the person in front of us right?
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@adamdobson123
I know this is controversial but I rarely test dermatomes
1. Because I prefer to believe them when they tell me they have altered sensation
2. Because the results would not change my triage decision 3. Because it takes a lot of time that I can use for something more impactful
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DRE is 'not necessary' for cauda equina assessment, as stated in the new CES GIRFT pathway:
It has low diagnostic accuracy with a high risk of false reassurance and is not recommended in the diagnostic workup:
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Great talk by Ben Davies about RECODE-DCM. Priority number 1 is raising awareness of DCM amongst clinicians and the public
How do we raise public awareness without raising alarm?
How do we scale up DCM education to clinicians nationally?
#BritSpine2023
#dcm
#myelopathy
#recode
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@DrProudman
If we publicly disclosed any personal details like this about our patients, we would quite rightly lose our jobs. Why is it ok for the police force to share this deeply personal information with the whole world? I don't understand.
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@Chris_Riggers
@Parody_RCGP
So tricky. A sense of genuine unease is definitely a red flag for me, but I agree that messaging is very alarmist in the last couple of years. We told everyone at the start of COVID to stay home even if they were dying and now we are telling them to get tested for everything.
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Absolutely LOVE this post Nick. We are all still learning. Every day is a school day.
Feedback is a gift not a weapon. You used it to help improve your practice and even better you shared the learning with everyone in your industry.
Awesome.
#feedback
#learning
#share
I have something that I’ve been wanting to share for the past few weeks…
But I wasn’t quite sure how…
Mostly cause I’m still working on processing the value it provides…
But 3 weeks ago, for the first time in my career…
I got a negative Google review.
🧵
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Loved delivering my Lumbar Spine workshop to Pure Physio yesterday. Covered spinal red flags, canal stenosis, cauda equina, radiculopathy, visceral pain, spondylolysthesis, axial spondyloarthritis and spinal MRI interpretation. Great shared learning☺️
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@physiotalk
That discrimination still exists in our profession
#appalling
That we don't have enough physios in senior leadership roles
That the public still don't understand what we do.
That we are underfunded and underappreciated
#physiotalk
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@ABBIE_ACP
Hi Abbie. Are you planning to write up/publish your results? Would love to see the detail
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@mikeinglephysio
VERY good point. You should do a poll on this.
Is it better to use tests of questionable diagnostic accuracy which might cause more harm than good to try and proove/disprove what they have told you? Or is it better to just believe what they have told you?
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@trentconsultant
Sorry Mike, I don’t get it. Why is it wrong for the GMC to expect people to be kind, courteous and respectful? That’s what all professionals should do surely?
I think we need to avoid encouraging an ‘us and them’ mindset between medics and non medics. We’re all on the same side.
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@adamdobson123
Nicely demonstrates how flexion opens the spinal canal and extension closes it. When looking for myelopathy, some countries in Europe MRI the neck in flexion and extension to capture the ones who only show up in extension. In the UK we typically only scan in neutral.
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@BillingMartin
@RogerKerry1
@alantaylor1
@DrFirasMourad
@HRCH_NHS
Just trying to find a home for it currently. Will update once done.
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Loving that DRE is no longer recommended in the new cauda equina pathway :)
With regards the 2 week cut off: consider progression, severity, complexity and risk factors as well as duration
#wholepicture
#clinicalreasoning
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Love this Aoife. Acute care saves lives, rehab saves people. Beautifully put.
This is literally why
#NHSfunding
for rehabilitation after any sort of critical illness cannot be an after thought. Organ support, drugs & acute care saves lives - access to rehab saves people.
Thanks for sharing your journey
#rehablegend
Source: TikTok @ tinabridge
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Such an inspiring talk about unconscious bias by Shreya Srinivas
@BritSpine
. SO interesting.
See here if you want to discover your own biases:
Thank you Shreya ☺️
#BritSpine2023
#liftasyouclimb
#inclusivity
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@f_diffley
@thomas_jesson
@Mercephysio
@adamdobson123
@michangus
@DrJN_SportsMed
@ClementsCharl96
This is a good place to start for spinal red flags:
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@adamdobson123
@myelopathyorg
FYI Adam, there is diagnostic criteria in sight. The RECODE DCM diagnostic incubator have submitted systematic reviews defining diagnostic signs and symptoms, pending publication. Watch this space ☺️.
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@Retlouping
I call this ‘the root below rule.’
Most discs will catch the nerve root below e.g. a 4/5 disc will catch the L5 NR, a 5/1 disc will catch the S1 NR. This is true all the way up the spine including in the neck.
Only exception is far lateral discs which can catch the NR above
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@BWhybrowPhysio
I totally agree that delivering unwelcome news is not always about cancer. This infographic from the HEE unwelcome news framework is helpful and there is more info with videos in the framework. Can be applied to any difficult conversation
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@DrJN_SportsMed
If bilateral hand paraesthesia the only symptom/sign, I would probably rule out CTS, B12, alcoholism, PVD, medication side effects, TOS, etc first and safety net for DCM. If all that was normal I might consider cervical MRI, but only if it would change mgt. No right/wrong tho
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Over scanning and under scanning are both equally harmful. We don't need to image the majority of people with MSK pain, but if there is any suspicion of serious pathology, including more subtle 'early stage' red flags, 2 choices: image or refer. Trust your gut. Comments welcome
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Why do some people pile in with derisory, judgemental comments when someone gets it wrong? At what point did this become ok? We all make mistakes. Let's give kind and constructive feedback to help people reflect and learn, instead of feel attacked.
#safelearning
#BeKind
#csp
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Loving the new
@NatSpineNetwork
shared space page on their website. Such a great place to store high quality clinical resources. See link below to join and access. Already has great resources on LSS, CES, spinal fractures, etc, but loads of potential to add more. Exciting ☺️
2/2
Already, we have content related to:-
GIRFT CES Pathway docs
NHS LBP pt facing info
Shared decision-making tools
LSS guidelines
Spinal injections pathways
Clinical competencies
Join us!! Become a member, learn from good works and share your own.
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Absolutely love this
@adamdobson123
thank you! A must read for anyone who sees people with lumbar radiculopathy
Let’s talk about escalating and deescalating care in painful lumbar radiculopathy. I am often asks when I should refer my patient on – usually in reference to time to onset. ⚡️⚡️⚡️
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@ClementsCharl96
@adamdobson123
Totally agree myotomal weakness can improve. Need to beware it might not though. If acute myotomal weakness 3 out of 5 or less, I order an urgent scan, prescribe myotomal strengthening and only refer on if no improvement once scan done. 80% improve. Love your exercises 👍
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Thanks to those of who have asked for references on DCM incidence. Some useful stats in here
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Final call for the virtual spinal masqueraders workshop 13th November. Explores early detection of spinal mets, MSCC, fracture, infection, AAA, MS, myeloma and much more. Perfect for FCP's but relevant for all MSK clinicians.
Email: jtabrah
@sky
.com ASAP to secure your place
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@elicia__austin
@theLDphysio
@RogerKerry1
@alantaylor1
@DrFirasMourad
@HRCH_NHS
It's primarily aimed at physios, osteos and chiros working in primary, community or private care, but might be useful for others.
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@adamdobson123
@Martin_Nekkolai
Its exhausting. But I think we as a medical profession have created this problem. If we use words like degenerative, disease, chronic and sinister, how can we blame patients for thinking their spine is crumbling? We seriously need to think about the impact of our language.
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@DrSethPT
Its often physically impossible to write all the notes retrospectively. There isn't enough time and most people cannot accurately recall all the info. As long as we give good eye contact, listen, empathize and strike the balance, I think some multitasking is fine.
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@adamdobson123
Nice share Adam, thanks.
This is another good resource for info and resources on myeloma diagnosis in case it’s helpful:
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@MinseokPhysio
@thomas_jesson
I think the language can be a bit confusing. Peripheral neuropathy is bilateral non-dermatomal paraesthesia/weakness caused by diabetes, alcoholism, B12 deficiency, etc. This article is about peripheral entrapment neuropathies which are totally different.
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@adamdobson123
@chadcookpt
@TDekkersPhysio
Yes, but I only supported from the wings.
It was
@LindsayTetreaul
who ran the project and did an awesome job of running the publication gauntlet
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Thank you to the CSP for publishing this response to the Daily Mail article.
Rob, will this be published any wider? It would be good to share it with the mainstream media to reach the public and other healthcare professionals
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@MRheumy
Totally agree. We need a national strategy to upskill primary care and community care clinicians in rheumatology triage. Maybe you should conveen a meeting with all the rheumy geeks to discuss how to achieve this? Happy to help if I can ☺️
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@SeanGTGibbons
@cmphysio
Totally agree. If they don't have diabetes, alcoholism or any other obvious cause, blood tests should be considered. We had a case recently of nitrous oxide abuse causing B12 deficiency. She had bilateral peripheral neuropathy symptoms with frank distal weakness.
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@penaverde_alan
@adamdobson123
Totally agree that red flags are key. I deliver weekend courses on spinal masqueraders and have published research on spinal red flags:
Dermatomal alteration is not a red flag. Trust me.
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@DrJN_SportsMed
I've had loads of these over the years where they have severe or critical canal stenosis but no acute bladder, bowel or saddle symptoms. I always call them straight away to check for CES, safety net and confirm they are happy to be referrred for an urgent surgical opinion
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@physiotalk
Support workers are the foundation of our profession and crucial to our ability to adapt and continually improve services. We need to create career progression frameworks for support workers with resourced training and development
#physiotalk
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@DrJN_SportsMed
Impossible to tell without more slices and more info but could be AxSpA with a scoliosis
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@nicklivadas
@thecsp
@NatSpineNetwork
@APPN_physio
We are using a graded approach because my physios have never done this before. Medics get undergrad training in breaking bad news. Physios don’t. We shouldn’t throw APPs in at the deep end. Also need some time to sort 2ww logistics. Will do it all eventually
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@DrJN_SportsMed
Could you have just ordered plain films to assess the Cobb angle? Unless I’m suspecting other pathology I usually start with XR for scoliosis. I don’t think there’s a right or wrong though.
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@physiotalk
We need better representation in the national media to promote physiotherapy in all sectors. I have worked in the NHS my whole career but we need to promote our profession as a whole and show that all sectors are united
#physiotalk
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@physiotalk
Encouraging working from home to cut down traffic pollution, going paperless, switching to online voting for CSP council elections (this will also engage with the membership in a more modern and interactive way)
#physiotalk
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Loved presenting at vPUK today, some great speakers this year. Watch below to discover the latest evidence on reliability of DRE for diagnosing cauda equina compression. Please feel free to share thoughts...
#physio21
#VPUK21
#proudtobeaphysio
#Vimeo
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@physiotalk
@thecsp
Hi I'm Julia Tabrah and I'm standing for council because I am passionate about physiotherapy and I want to ensure that the CSP listen to, engage with and represent all members. I'm compassionate, I'm assertive and I'm listening
#physiotalk
@thecsp
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Loved delivering the cervical workshop yesterday. Lots of shared learning, interaction and amazing feedback....thanks guys!
#sharedlearning
#advancedpracticephysio
#neckpain
#cervicalmyelopathy
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@DrLucyDouglas
@GatesPhysio
Agree these questions can go down like a lead balloon. I sometimes ask them and sometimes don't, depending on the person in front of me. They can be hugely useful in some cases. Adapt to the individual.
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@CorKinetic
No, but I would use questioning to screen for them. Especially if the pain is non-mechanical or atypical.
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@thomas_jesson
@BrianCarroll83
@CombatSportPhys
@michangus
I always assume that any recent change to bladder function could be relevant and the rest is down to clinical reasoning, thorough questioning and an awareness of national guidance:
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@adamdobson123
Ah thanks Adam ☺️ Agree lumbar spine is similar.
In the cervical spine cord signal change will show regardless of positioning, but scanning in neutral might miss the ones who are pre-signal change and only compress in extension e.g. symptoms mainly come on in the shower
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