follow-up on EBP

[JR]

ok you guys, i'm back as promise to start the basics of EBP. also, i would like to mention that including in this forum section pertains to discussions on research articles, eval and treatment protocols/algorithms that you can use in the clinic. as far as the journals that we will use, it will include but not limited to the ff:

a. American Journal of Sports Medicine- AJSM
b. Journal of Orthopedic and Sports Physical Therapy- JOSPT
c. Spine
d. Foot and Ankle International
e. Journal of Bone and Joint Surgery- JBJS American edition
f. Physical Therapy Journal

and for searching databases, we'll use the ff:

a. PubMed www.ncbi.nlm.nih.gov/pubmed
b. Medline Plus www.medlineplus.gov
c. PEDro www.cchs.usyd.edu.au/pedro
d. Hooked on evidence www.apta.org/hookedonevidence
e. US National Library of Medicine www.nlm.nih.gov

for EBP tutorials

a. UNC Evidence-Based www.hsl.unc.edu/ebm/index.htm
b. Duke Evidence-Based www.mc.duke.edu/mclibrary/respub/guides/
ebm/html
c. Evidence-Based Medicine Working Group (EBM Toolkit)
www.med.ualberta.ca/ebm

for case-studies

a. Evidence-Based Physical Therapy www.library.utoronto.ca/medicine/
ebm/syllabi/physio
b. PT Central www.ptcentral.com

and for search engines

a. yahoo www.yahoo.com
b. lycos www.lycos.com
c. google www.google.com
d. alta vista www.altavista.com
e. askjeeves www.askjeeves.com

whew!!! i apologize! i know it's a lot of information. but this will help you organize. i don't expect you to subscibe to the journals coz' they are expensive, however the databases and sometimes the search engines will allow you to download abstracts and articles for free. I'm not aware of any PT journal in the phil, i mean like PPTA journal or the likes. if there's one, pls feel free to post it and share the research articles. again, this is not meant to bore you or fry your brain but rather improve our understanding of the things that we do in the clinic, why they work or not, and what's current out there. so, let's roll and have fun!

[JR]

hey guys it's jr again. my agenda today is to define evidence-based practice and review of some basic research designs and statistical parameters. i'm not going to discuss them in details because i'm under the assumption that all of you out there have encountered this in school and through cont eds, books and journals.

why practice EBP?

currently, physical therapist practice in a very competitive and highly driven managed care environment. the constant scrutiny of how we deliver physical therapy from insurance companies, patients and other healthcare professionals, creates this need. we have to prove to them that what we do is measurable, effective and justified. as far as i know, physical therapy in the philippines does not have managed care (pls correct me if i'm wrong). so, maybe the pressure to effectively treat patient in a short period of time is not as great. i don't mean to say that patients there are not treated effectively. it's just a different environment. but then again, i still believe that EBP should be across the board. we are the practitioner of choice for neuromusculoskeletal conditions including movement dysfunctions. therefore, we should be experts in these subspecialties.

what is EBP?

Sackett defined EBP as " the conscientious, explicit, and judicious use of the current best evidence in making decisions about the care of individual patients." Spine 1994

Sackett et al recommend that treatment decisions be made from: clinical expertise, patient values and clinical expertise.
- Evidenced-Based Medicine: How to Practice and Teach EBM. 2nd ed.
Edinburgh. Churchill Livingstone; 2000.

EBP doesn't mean you have to read all journals, scour all research articles that you can find or not apply what you knew when the evidence is not there. it's not the panacea to every case that you will encounter in the trenches. EBP is not like a protocol that you will have to follow every single time. we have to remember that each patient is unique in their clinical presentations, values, goals and healing capabilities. lastly, we also have to consider our own clinical skills because we directly influence their success or failure in therapy.

so, how do we go about practicing evidence-based physical therapy?

well, again Sackett et al outlined in their book the process of EBP and they are as follows:
a. identify a patient problem. derive a specific question.
b. search the literature
c. appraise the literature
d. integrate the appraisal of literature with your clinical experience,
patient values and unique circumstances
e. implement the findings
f. assess outcome and re-appraise

when do you apply EBP then?

if possible to every patient that we see but the reality is that we don't have time and the resources to read journals 365 days. in a lot of ways, complex cases needs EBP because uncertainty in managing the patient is present. we have to consider the benefits and the risks of our interventions. again we have to integrate everything that we know based on our training, consider the patient clinical presentation and current evidence. remember, what we've learned before may not be true anymore. a good example is the lat pull down exercise. we were taught in our entry level program that we pull the bar down behind the neck. guess what, it's wrong! this position places the shoulder into the high five position of abduction and ext. rot (ant instability), stressing the rotator cuff in an impingement position and puts the cervical spine into an excessive forward head tilt position (1,2,3). also transient brachial plexus injury with increased forward head position with the repetitive motion can occur (4).

ref: 1. Gross et al AJSM 1993
2. Reeves et al Physican Sporstmed 1998
3. Risser et al Am J Dis Child 1990
4. Shea, JM Physician Sportsmed 1986

for now, i'm going to finish this discussion and i'll be posting new topics next time. hopefully today's information helped somewhat. so, until then.

JR

[pt2003]

Good day! Hi there!!! i think this is a good idea! i just graduated last year and still in a process of getting familiar about our profession! hehehe! i mean i have so many things to learn .... to be honest with you i really love my profession....i would like you to know that i'll be hearing from you soon. just that i really want to learn more...i don't know how to that but i think i will...Good luck to all p.T. out there!! ;D

[ecalica428]

This is a sample of an EBP which ive done for my case presentation that i submit here in the UK.

tennis elbow:

Outcome:

After 3 treatment sessions, Physiotherapy given was effective although there is a lack of current evidence based practice, giving the treatment selected improved the condition and the patient was pleased with the results.
Patient is happy to discontinue physio rehabilitation based on current status of her tennis elbow however, was advised to come back for an appointment after 3 weeks for review. She was also notified that if symptom appears again she can contact the department and continue physiotherapy.







Wrist muscle pathology in lateral epicondylitis

The morphology of the ECRB muscle was investigated in 20 patients with long standing lateral epicondylitis. Muscle biopsies were obtained from the proximal or distal portions of the ECRB and analyzed by enzyme and immunohistochemical methods.
Morphological abnormalities were significantly more frequent in patients than control including moth eaten fibres, muscle necrosis. Changes were equally distributed proximally and distally. It is concluded that these changes, directly or indirectly, may reflect the cumulative effect of mechanical and/ or metabolic overload and that decreased muscular performance in patients with tennis elbow may be due to both elbow pain and physical damage to the ECRB muscle.( Ljung BO, Lieber RL, Friden J. J Hand Surg
., 1999 24(2): 177-83.


What is the most effective treatment for tennis elbow?

It is often prescribed rest, exercises, NSAIDs, physiotherapy, corticosteroid injection for tennis elbow. Is there any evidence to support this treatment or any treatment of value? As for this case presentation I would concentrate on the alternative physiotherapy modality that I know would somewhat help treating my subject alleviating her condition based on the fact that clear recommendation on treatment regime are difficult to formulate as there are few good quality trials.


Evidence:

• Corticosteroid injections appear effective in treating tennis elbow in the short term (2-6 weeks) but appear to have no long term benefit ((1) Assendelft et al).
• NSAIDs have no good evidence to support their routine use in the treatment of tennis elbow. However NSAIDs are reasonably effective as analgesics but debatable whether there is any advantage in their use over simple analgesic ((2) Hay et al, (3) labelle et al.)
• Topical NSAIDs studies tend to be small and of poor quality, but do continually suggest that it can provide short term pain relief for tennis elbow ((4) Burnham et al).
• Physiotherapy also has no clear evidence of benefit in the treatment of tennis elbow. On the studies, a wide array of physiotherapy methods are used including strengthening, stretching, laser, ultrasound, and friction massage. Physiotherapy choices seem to be driven by tradition or are based on poor quality trials (5).
• Forearm brace studies are of poor quality and small , but the majority of them report forearm (FA) brace are effective in helping to alleviate pain in tennis elbow (6),(7).
• Ultrasound use also has no convincing evidence for its use in tennis elbow (8).
• Laser Therapy at 904nm low level has no evidence on the effectivetiveness for treating tennis elbow (9).None of the studies found laser to be effective in reducing pain or improving function in tennis elbow.
• Acupuncture studies consistently show can have an analgesic effect but studies tend to be small, and of poor quality (10) (11).
• Surgery can be effective treatment for tennis elbow for most studies suggest especially for cases not responding to conservative treatment for tennis elbow (12)(13)(14)



Search method:

Databases searched: Medline, Bandolier, Cochrane library, Pubmed


Evidence-based Evaluation of Present Guidelines for the Treatment of tennis Elbow (Theis C, Herber S, Meurer A, Lehr HA, Rompe JD) (Meta Analysis 2004 August)

To date there exists no evidence-based therapeutic algorithm for the treatment of acute and chronic tennis elbow. Even medium term effects should be as either a placebo effect or natural regression to the mean.

[mpt]

Hello!

Good job ecalica! I believe in EBP too!

Anyway I was just wondering, what was that alternative physiotherapy modality you mentioned? What forms of treatment did you give the patient?

:)mpt

[ecalica428]

ok this is the case presentation that i did. sana lang ay wag kopyahin ng mag aapply para sa HPC kundi gawin lang guide para malaman nila ang pattern.

At hindi basta basta gumawa nito.

IT took me 3 months to do my case presentation on 3 subjects. 1 neuro, 1 respiratory and 1 musculoskeletal.
since applicants in the HPC have problems in finding a placement for thier adaptation, the HPC then focused on doing case presentions.
ang mahirap lang sa isusulat mo ay since wala ka dun para i depend yun ginawa mo, dapat yun gawa mo ay sya na mismo ang magdedepend sa sarili nya.

Case Presentation: Musculo-Skeletal

Tennis Elbow

General Information:

This is the case of K.C a 35 y/o Caucasian female diagnosed to have Right (®) tennis elbow. She was referred by her GP (29.07.2004) to the Physiotherapy clinic for further evaluation and treatment due to pain and stiffness for over a year on her right lateral elbow. She received Depo-medrone injection twice and non-steroidal anti inflammatory tablet (NSAID). This gave some symptomatic relief, she was still getting significant problems. She was not at all keen on further Depo-Medrone treatment but was keen for further interventions.


History of Present Illness:

The present condition started 1 year ago when she experienced sudden pain on her (®) lateral (lat.) epicondylar area and stiffness on the elbow without any apparent reason. She could neither identify any particular activity that aggravates the condition nor did she know any activity to ease the pain.


Session 1

Initial Evaluation: (25.08.2004)

• Informed consent leaflet given and explained.
• Risk assessment done e.g. noting anything that would hamper treatment or need to be referred to other members of the team.
• no x-ray done
• Vital signs assessed and within normal limits (WNL)
• Not on any medication
• Card / stationary shop owner/employee, balloon art decorator.





Subjective Examination (S):

C/o intermittent dull and aching pain 8/10 on the visual analog scale (VAS) (0 – no pain; 10 worst possible pain) and stiffness on ® lat elbow which worsened in the afternoon and evening and often woke her up during the night for the past 12 months.


Objective Examination (O):

On examination there is tenderness over the right lateral epicondyle over the origin of ECRB and the pain is increased with resisted wrist extension; the pain is greater with a straight elbow and radially deviate the wrist. Middle finger test was done and resulted positive upon eliciting pain on the ® lateral epicondyle when I resist extension of the proximal inter phalangeal joint of digit 3.
Muscle strength and Range of Motion (ROM) passively and actively done was taken and found to be within normal limits. Trigger points were noted along ® elbow extensor group but namely on belly of ERCB which elicits pain upon deep finger pressure. Patient tested positive on Special test # 2 for tennis elbow test upon eliciting pain on origin of ® ECRB on lateral epicondyle (entesiopathy in origin).



Analysis (A):


Inflammation between ® lateral epicondyle and ECRB and stiffness and tenderness of the ® lateral elbow extensor muscle group specially the ® ECRB superior muscle belly of idiopathic origin with an on / off episodes but mostly in the late afternoon and evenings.

Problem Identified:

• C/o intermittent dull and aching pain 8/10 in VAS on ® epicondylar area extending to superior muscle belly of ® ECRB which sometimes wake her up during the night.
• Trigger points, muscle tenderness Grade 1 (see Table 1) along ® lat. epicondylar area which elicits pain upon deep finger pressure.
• Stiffness that gradually diminishes but worse in the afternoon and evening.( Stiffness tends to be just patient’s perception of inability to move the ® elbow joint during the flare up of the condition)



Plan (P):

(Since this was a 30 minute triage or a pre assessment for the patient (Pt). She was instructed to do a home exercise treatment program and take any notice on the status on the affected part (® elbow) and noting what activity/movement that would likely increases severity of the condition)

Home Exercise Treatment program:

• Eccentric contraction of ® wrist extensors x10 repetition with 7 seconds hold (demonstrated with drawings given) twice/ day
• Stretching of the ® wrist extensor muscles with ® elbow extended and wrist fully flexed x10 repetition x 15seconds hold (demonstrated with drawings given).


Physiotherapy management Plans:

Clinical Reasoning:

Hot Packs:

I plan to use hot packs or heat instead of cold/cryo therapy as a form of treatment because of the stiffness she is complaining about. If I use cold as a form of treatment to control the pain I would be most likely to increase the amount of stiffness she is getting at the moment by reducing the blood flow to the affected area (vasoconstriction). Most tennis elbow sufferers respond to either hot or cold therapy but in her case, I would say, it would benefit her if I use heat to increase peripheral circulation and pain control and promote healing.



TENS:

I plan to use TENS in conjunction with hot packs to facilitate the pain control or analgesia exhibited by these modalities.
Long DM. Fifteen years of transcutaneous electrical stimulation for pain control. Stereotact Funct Neurosurg. 1991; 56:2-19
McQuay HJ, Moore RA, Eccleston C, Morley S, Williams AC. Systematic review of outpatient services for chronic pain control. Health Technol Assess. 1997; 1:1-135
Spencer JW, Jacobs JJ. Complementary/Alternative Medicine: An Evidence-Based Approach. St. Louis, MO: Mosby, Inc; 1999.

Deep Transverse Friction Massage (DTFM):

Deep transverse friction massage is one of several physiotherapy interventions suggested for the management of tendinitis pain (16). . I plan to use DTFM to provide movement in the tissue and stimulate proteoglycan synthesis, orient new collagen fibres and prevent intermolecular cross links. The aim is to return the tissue to a normal state by letting blood, lymph and nerve transmission flow through to the area involved.

Stretching:

Stretching the muscle tends to stimulate the Golgi tendon organ thereby relaxing the muscle as a protective mechanism.

Eccentric Contraction

Eccentric contractions are a very important type of muscle contraction. They are responsible for slowing movements down, and then reversing the direction. Study shows eccentric exercise programme helped up to 82% on most tennis elbow sufferers or tendonopathies to avoid surgery (15).

[ecalica428]

Part 2:

Session 2 (06.09.04)

Treatment # 1

Informed consent given

S:

Patient noted no change in her condition and still in pain 8/10 on the VAS
and feels stiff. However she noted some relief when she was stretching the affected part especially when the ® elbow was extended and stated that pain intensity increased when doing bowling while on vacation during the previous week.

O:

Palpation: (+) muscle tenderness and trigger points were noted on ® ECRB

Sensory Assessment:

Superficial sensation Temperature Test: Results: Negative

Patient was ask to distinguish between Hot and cold perception when tested on 2 test tubes containing each of ice and hot water.

Tested for any abnormality on the thermal receptor in the skin and the thalamus via lateral spino thalamic tract in spinal cord. Prior to giving hot packs and prevent burns.

Pain sensation test: Results: Negative

Patient was asked to recognize a stimuli (A pin that has a sharp and a blunt end was used) and verbally indicate if that is a sharp pin or a blunt one was been stroked to the skin and where the stimuli was felt.

Tested for any abnormality on the pain receptors (Exteroreceptors) in the skin and the antero lateral spino thalamic pathway. Prior to giving Transcutaneus Electrical Nerve Stimulation (TENS).

Assessment:

She noted some relief when stretching ® elbow into extension with her ® wrist fully flexed and aggravated by doing bowling during on her holiday. Patient was asked to note other details as to which activity would likely to increase severity of her condition.



Plan:

Formulate an intervention appropriate to improve her condition and educate her about tennis elbow. (Leaflet given about tennis elbow.)

Physiotherapy Management:

• Hot Packs (Hot moist pack or HMP) x 10 minutes in 8 towel wrap placed on ® superior border of dorsal aspect of forearm (FA).
• TENS x10 minutes on 50 Hz intensity 4 (increase gradually when accommodation occurs) 1st electrode placed on ® lateral epicondyle and 2nd electrode placed 3cm diagonally to the left.
• Deep transverse pressure/friction massage on ® ECRB x 3 minutes
• Stretching of ® ECRB x 15 seconds hold x10 repetitions



Future treatment plan:

• Continue present Physio management and check progress and response to treatment next visit.


• To consider giving Ultrasound treatment after 3 treatment session if she would not respond to current physiotherapy interventions because according to evidence, it suggest that ultrasound treatment may be of benefit for treating tennis elbow and improving general symptoms.(Bandolier - Van der Windt DAWM, van der Heijden GJMG, van den Berg SGM, ter Riet G, de Winter AF, Bouter LM. Ultrasound therapy for musculoskeletal disorders: a systematic review. 1999; Pain 81; 257-271

Patient was reminded to continue exercise given and was asked to show exercise given if she’s doing it properly.


Session 3 (13.09.2004)


Treatment # 2


Informed consent given.

S: Pt reported relief. Stated less pain 6/10 from previous 8/10 on VAS on the affected part and with less stiffness. Patient was happy with the outcome.
O: Palpation; affected muscle are more relaxed with less trigger points and muscle tenderness. muscle tone is getting better.
A: Patient was responding positive on current physio management and reported that stretching and DTFM helped her a lot when pain and stiffness are present.
P: Same physio management (06.09.2004) was given to the patient and only increased the intensity (previous 4) of TENS unit to 5.

Plan for next visit:

Would continue current Physio management and would defer Ultrasound therapy because Patient is responding well on present interventions.














Session 4 (20.09.2004)

Treatment # 3

Progress note

Informed consent

S: Patient reported pain and stiffness free for the past 4/7. Although there is still some nagging pain but is more tolerable and less in frequency. Patient was pleased of the outcome and stated condition was a lot better compared to the Cortisone and NSAID received.
O: Palpated some trigger points on belly of ® ECRB although went back to normal after applying DTFM.
A: Patient condition improved a lot after 2 treatment sessions and responding well on current interventions. Patient was advised to continue Home exercise program.
P: Same previous management to be given but will remove the TENS because pain is more controlled. (The rationale for retaining the hot pack is to increase peripheral circulation on the affected part and promote healing.)




Outcome:

After 3 treatment sessions, Physiotherapy given was effective although there is a lack of current evidence based practice, giving the treatment selected improved the condition and the patient was pleased with the results.
Patient is happy to discontinue physio rehabilitation based on current status of her tennis elbow however, was advised to come back for an appointment after 3 weeks for review. She was also notified that if symptom appears again she can contact the department and continue physiotherapy.

[ecalica428]

Wrist muscle pathology in lateral epicondylitis

The morphology of the ECRB muscle was investigated in 20 patients with long standing lateral epicondylitis. Muscle biopsies were obtained from the proximal or distal portions of the ECRB and analyzed by enzyme and immunohistochemical methods.
Morphological abnormalities were significantly more frequent in patients than control including moth eaten fibres, muscle necrosis. Changes were equally distributed proximally and distally. It is concluded that these changes, directly or indirectly, may reflect the cumulative effect of mechanical and/ or metabolic overload and that decreased muscular performance in patients with tennis elbow may be due to both elbow pain and physical damage to the ECRB muscle.( Ljung BO, Lieber RL, Friden J. J Hand Surg
., 1999 24(2): 177-83.


What is the most effective treatment for tennis elbow?

It is often prescribed rest, exercises, NSAIDs, physiotherapy, corticosteroid injection for tennis elbow. Is there any evidence to support this treatment or any treatment of value? As for this case presentation I would concentrate on the alternative physiotherapy modality that I know would somewhat help treating my subject alleviating her condition based on the fact that clear recommendation on treatment regime are difficult to formulate as there are few good quality trials.


Evidence:

• Corticosteroid injections appear effective in treating tennis elbow in the short term (2-6 weeks) but appear to have no long term benefit ((1) Assendelft et al).
• NSAIDs have no good evidence to support their routine use in the treatment of tennis elbow. However NSAIDs are reasonably effective as analgesics but debatable whether there is any advantage in their use over simple analgesic ((2) Hay et al, (3) labelle et al.)
• Topical NSAIDs studies tend to be small and of poor quality, but do continually suggest that it can provide short term pain relief for tennis elbow ((4) Burnham et al).
• Physiotherapy also has no clear evidence of benefit in the treatment of tennis elbow. On the studies, a wide array of physiotherapy methods are used including strengthening, stretching, laser, ultrasound, and friction massage. Physiotherapy choices seem to be driven by tradition or are based on poor quality trials (5).
• Forearm brace studies are of poor quality and small , but the majority of them report forearm (FA) brace are effective in helping to alleviate pain in tennis elbow (6),(7).
• Ultrasound use also has no convincing evidence for its use in tennis elbow (8).
• Laser Therapy at 904nm low level has no evidence on the effectivetiveness for treating tennis elbow (9).None of the studies found laser to be effective in reducing pain or improving function in tennis elbow.
• Acupuncture studies consistently show can have an analgesic effect but studies tend to be small, and of poor quality (10) (11).
• Surgery can be effective treatment for tennis elbow for most studies suggest especially for cases not responding to conservative treatment for tennis elbow (12)(13)(14)



Search method:

Databases searched: Medline, Bandolier, Cochrane library, Pubmed


Evidence-based Evaluation of Present Guidelines for the Treatment of tennis Elbow (Theis C, Herber S, Meurer A, Lehr HA, Rompe JD) (Meta Analysis 2004 August)

To date there exists no evidence-based therapeutic algorithm for the treatment of acute and chronic tennis elbow. Even medium term effects should be as either a placebo effect or natural regression to the mean.







Conclusion:

After carefully considering the facts and details about my subject and having done thorough research about Tennis Elbow in regards to Evidence Based Treatment and Practice and Current Guidelines, there exists no treatment protocol for tennis elbow for the Physiotherapist.
Therapy for tennis elbow therefore depends upon skills and clinical reasoning of the Physiotherapist and which he/she feels comfortable or appropriate for the condition. The therapist needs to gather enough information trying to eliminate or modify the movement or stresses on the joint or muscle. Educating the patient about the Disease and involving patient participation in the treatment program would continue to help improve the condition.




Table 1

Grading tenderness on palpation

Grade 1 Patient complains of pain
Grade 2 Patient complains of pain and winces
Grade 3 Patient winces and withdraws the joint
Grade 4 Patient will not allow palpation of the joint
















References:

(1) Assendelft W, Hay E, Adshead R, Bouter L. Corticosteroid injections for lateral epicondylitis: a systematic overview. Br J GP. 1996; 46: 209-216.
(2) Hay E, Paterson S, Lewis M, Hosie G, Croft P. Pragmatic randomised controlled trial of local corticosteroid injection and naproxen for treatment of lateral epicondylitis of elbow in primary care. BMJ. 1999; 319: 964-968.
(3) Labelle H, Guibert R. Efficacy of diclofenac in lateral epicondylitis of the elbow also treated with immobilization. Archives of Family Medicine. 1997; 6(3):257-62.
(4) Burnham R, Gregg R, Healy P, Steadward R. The effectiveness of topical diclofenac for lateral epicondylitis. Clinical J of Sport Medicine. 1998; 8(2):78-81.
(5) Beckerman H, Bouter L, Heijden G, Bie R, Koes B. Efficacy of physiotherapy for musculoskeletal disorders: what can we learn from research? 1993. Br J Gen Pract; 43:73-7.
(6) Verhaar J. Tennis elbow. 1992. Maastricht, University Press.
(7) Froimson A. Treatment of tennis elbow with forearm support band. J of Bone and Joint Surgery 53A:183-184, 1971.
(8) Van der Windt D, van der Heijden G, van der Berg S, ter Riet G, de Winter A, Bouter L. Ultrasound therapy for musculoskeletal disorders: a systematic review. 1999; Pain 81; 257-271.
(9) De Bie R, Verhagen A, Lenssen A, de Vet H, van den Wildenberg F, Kootstra G, Knipschild P. Efficacy of 904 nm laser therapy in the management of musculoskeletal disorders: a systematic review. Physical Therapy Reviews 1998, 3(2), 59-72.
(10) Molsberger A, Hille E. The analgesic effect of acupuncture in chronic tennis elbow pain. Br J Rheum. 33(12):1162-5, 1994.
(11) Brattberg G. Acupuncture therapy for tennis elbow. Pain. 16(3):285-8, 1983.
(12) Binder A, Hazleman P. Lateral humeral epicondylitis- a study of natural history and the effects of conservative therapy. Br J Rheum 22:73-76, 1983.
(13) Kamien M. A rational management of tennis elbow. Sports Med 9(3):173-191, 1990.
(14) Bankes M, Jessop J. Day-case simple extensor origin release for tennis elbow. Arch Orth & Trauma Surg. 117(4-5):250-1, 1998.
(15) The Annual Congress of The British Association of Exercise & Sports Medicine held at Windermere, Prof K Khan, UniversityofBrit.Columbia, freespace.virgin.net/kevin.williams/Running%20Advice%20Pages/october_2002_training_advice-BASEM.htm).
(16) (Brosseau L, Casimiro L, Milne S, Robinson V, Shea B, Tugwell P, Wells G) Deep transverse friction massage for treating tendinitis (Cochrane Review)





The end.

[pt2003]

Thank you ...thank you sooo much...i never thought this would be the kind of test that i will be dealing if ever i will apply in h.p.c. I was surprised really.... but at least i have an idea right now...have some questions , are you working right now in u.k. as a physiotherapist? did you undergo an adaptation training? for how long? how many months? im just wondering if what exactly did the hpc ask you to comply in order for you to qualify? .....hope to hear from you soon....thank you so much.... i appreciate what your doing...GOD Bless!!!! ;D

[mpt]

Hi there PT2003!

You must consider a lot of things before applying for HPC registration. First of all, the scrutiny fee costs 200 pounds around 20k+php and it will go to waste if you will not submit a well prepared application. Even that is not an assurance to get registered, most foreign physios are asked to do an adaptation. But then again you can get rejected and you will need to appeal if you still want to pursue.

HPC is very keen on experience and they want you to have rotated in all areas and you need to prove it.

Hope this helps in your decision.

mpt

[pt2003]

Thanks for your reply...I really appreciate it.....just want to ask if where did you take your oral defense or case report ? here in the philippines or in u.k.? im just wondering if its really an oral exam or case preparation ( all written) ?....and are you done in your adaptation?.....thank you!

[ecalica428]

doing that case presentation was really tough. i did that one here in the UK and took me 3 months to prepare for my 3 written topics. yes MPT is right that when applying for hpc EXPERIENCE matters most and if you dont have. better not to apply because literally speaking our curriculum is totally different to them so they take your experience for consideration.
regarding adaptation. it is really hard to find an employer that will hire you as an adaptation student but know someone from EAC who just appplied in the net and manage to find one. but if you manage to secure a registration you can apply in an agency like like rs locums and etc..