Mr Andy Emms

Brief Outline:

Mr Andy Emms is a lead orthopaedic physiotherapy practitioner.

Background:

Mr Andy Emms is a lead orthopaedic physiotherapy practitioner at the Royal Orthopaedic Hospital NHS Foundation Trust and a tutor and honorary lecturer at The University of Birmingham.

More about me...

Mr Andy Emms leads clinics where he assesses, investigates and treats patients with othopaedic problems, including the spine and knee. He works alongside surgeons and physicians within their clinics.

Mr Andy Emms studied at the University of Birmingham as a charted physiotherapist, graduating in 1999. He chose to specialise in the diagnosis and treatment of musculoskeletal conditions.

Mr Andy Emms holds postgraduate diplomas in orthopaedic medicine and injection therapy. He gained fellowship to the Orthopaedic Medicine Society in 2011. He previously worked in the Pain Service at Dudley Hospital Group. In addition to his clinical practice, Mr Andy Emms lectures at both undergraduate and postgraduate level at the University of Birmingham.

A physiotherapist speaks on the importance of physiotherapy in managing knee problems and, for those due to have knee replacement, in prehabilitation.

So, physiotherapy can offer several different things to patients with osteoarthritis.
They can improve range of movement at joints, so sometimes joints get stiff and they get restricted with osteoarthritis, and physios can give exercises which can help improve that and also manual therapy techniques, which is where they mobilise and manipulate the joints with their hands. Massage, that can be helpful.

They can also improve the strength and the coordination around joints, which has been shown to be really important in people with osteoarthritis. That generally enables people to feel more supported, and steady and improve their function, ability to walk etc, ability to use upper limbs for everyday tasks.

And the final thing that physiotherapy can offer, which sometimes comes as a by-product of the other two that I've just mentioned, is pain relief. So, a joint that moves well, that is stronger, generally tends to hurt less when you ask things of it.

But there are other things that physios can offer: electrotherapy, acupuncture, usually in conjunction with exercise and manual treatments, that can help to reduce pain and inflammation around and within joints.

Physiotherapy definitely has a role in early osteoarthritis. So, when people first start to get symptoms, they may have had an X-ray that shows early changes within the joint.

Patients can make real progress with physiotherapy during that phase, because there's limited damage to the joint. The majority of the pain probably comes from the capsule, which is the sleeve around the joint, and physiotherapy can make changes to that. So, it's much easier to improve range of movement around a joint when you don't have bone-on-bone restrictions, if you like. And also, I suppose, the earlier you treat these things, the less muscle wasting and deconditioning will happen. So, do you see what I mean? It's not like you're taking the patient right back to a really limited state.

And as the osteoarthritis progresses, I think physiotherapy can still help. But I think it's less likely to make as much of a difference later on, although I wouldn't ever rule it out completely because as we know, the degree of osteoarthritic change on an X-ray doesn't always marry up with the amount of pain and disability a patient has.

So, I think, yeah, I think it's always worth thinking about, but probably more effective in the early stages.

So, there's a lot of interest around rehabilitation. And the general consensus is that the fitter and stronger you are before an operation, the better you will do following surgery. So, if you can go into an operation with a knee that's got good movement, with a joint that's well supported by muscles, and from a metabolic-, from a fitness point of view, you're in a good place. It probably fosters a good outcome following an operation.

A physiotherapist speaks on the importance of physiotherapy after knee replacement.

So, the physiotherapy, well, the physiotherapy begins with the prehabilitation really doesn't it, and then it's picked up again by the ward physiotherapists in the hospital.

So, what they do is they start exercises early. They can also work on treatments to reduce swelling and inflammation; cryo cuffs [cold compression], for example, can be used. They'll also work on a patient's mobility. So, they'll help them to get in and out of bed, up and out of the chair, walking initially usually with a Zimmer frame, usually, and then the patient is progressed on to elbow crutches and usually discharged on elbow crutches.

Most centres that I've worked in routinely refer all patients that have had a knee replacement for outpatient physiotherapy, and that's usually done on an urgent basis which should be no longer than a few weeks. So that the patient can be picked up and there's very little gap in their rehabilitation.

What will then happen is probably a bit variable from centre to centre and from clinician to clinician. But it would usually involve progression of exercises already started on the ward, so gradually building up somebody's strength, somebody's function. Those exercises will be done at home. But and how often the patient has outpatient treatment in terms of how often they attend is probably based on several factors really, but largely around the needs of the individual. So, some people are quite happy to be set a programme, to go home and to work on it, you know, based on their understanding of exercise, interest in exercise, experiences. Other patients need more guidance and would prefer to attend on a regular basis. I think it's really important that patients have that conversation with their therapist so that the program is tailored to what they need. And that can involve getting in the gym, sometimes there are classes that are put on, you know, group sort of exercise.

So certainly, the first three months are really important. We know that at that three-month point, most patients have healed very well. You know, they've got good movement, they're back to a reasonable level of function. But beyond that, I always encourage patients to be - for lots of different reasons - but to be continuing with some form of regular exercise to keep themselves fit and strong.

A physiotherapist explains why physiotherapy after knee surgery can help achieve a good outcome.

If you were to keep the joint still and stiff, then you could develop contractures, which is where the joint gets set and fixed in a particular position, which is incredibly difficult to treat afterwards. So even if you developed a contracture, even physiotherapy, it's not clear whether that will get that movement back. So, the early phase - that first few weeks - are crucial because that's when the joint is susceptible, I suppose, open to change and that's the time to get that range of movement back. As time goes on, it becomes more and more difficult.

The other thing I guess or the other factors is if people are in pain and they're frightened to move, they're frightened to mobilise, then they may choose not to. And walking around on a knee that's fixed and set and bent is incredibly difficult, so it will affect general function and mobility as well. The joint won't feel supported, it won't feel strong, it may give way.

So yeah, for a multitude of reasons, it's important.

A physiotherapist encourages patients to get the most out of their appointments and seek support on 'waiting well'.

I think it's really important that therapists listen to their patients, listen to their needs and concerns, and there's a lot of focus on this at the moment - it's called shared decision making. And understanding what matters to the patient. So, you know, what difficulties are they having at home? And it's important to drill down into the detail of that. I think it's wrong to assume that all patients are the same and that all patients need the same exercises or whatever, although that does go on sometimes, but I'd be- I'd encourage people to challenge that, and to make sure that the treatment is tailored for them. And that really will dictate how often they're seen, what the treatment involves, to make sure that the outcome is a good one.

I think just to just have an open and honest conversation with the therapist about what they're looking for. You know, what the patient is looking for. What their expectations are, what their goals are. And make sure that there's a mutual understanding between two people as to what really needs to be done. So, it needs to be guided by the patient, facilitated by the therapist, is probably the way I would put it.

We always try and treat patients holistically, taking into account other problems, whether they're joint problems or general health problems. So there may be certain positions that a patient can't get into or, you know, a certain activity that they find particularly difficult. For instance, they may have shoulder problems, you know, therefore getting down to exercise on all fours might be something that they just can't do.

So, I think while the physiotherapist should take these things into consideration, I think it's important for patients to flag it to the therapist. You know, if they have any particular concerns or difficulties. It really should be a two-way conversation.

I mean, unfortunately during the pandemic, patients’ treatment assessment and treatment was paused often, wasn't it? Or we tried to manage people the best that we could remotely, based on not being able to bring them into hospitals. And I guess all we can do from here going forward is to offer people the best service that we can in a timely manner, and give them what they need.

For people sitting on waiting lists, there is a focus in a lot of organisations at the moment, which is worth patients looking into, around what's called ‘waiting well’.

So there are things that can be offered to patients – whether it's exercise, whether it's pain relief, whether it there are certain apps that are out there that people can use, to allow them to stay well and fit while they're waiting to see the clinician. While in the background services try and get the waiting times down to an acceptable level.

A physiotherapist explains about steroid injections for knee osteoarthritis.

So, the way I look at steroid injections depends on the stage of the osteoarthritis really. So, as I think I mentioned earlier on, in the early stages of osteoarthritis where the joint is not too damaged, if you like, degenerated - it's the sleeve around the joint that's largely responsible for the pain. It's called the joint capsule. So, for patients with early osteoarthritis, it makes sense to me that if you inject steroid, corticosteroid, local anaesthetic into that joint, bathe the capsule in medicine, they're much more likely to have a good outcome because you're- it's the capsule that's causing the pain.

As the osteoarthritis advances, the capsule is still inflamed, that's for sure, but it becomes more about bone-on-bone pain. Which patients often describe as different. Now if you put steroid into a severely arthritic joint, you're likely to get temporary relief because while you’ll bathe the capsule and settle the capsule down, you're not going to do anything about that bone-on-bone pain. Certainly nothing prolonged, so the pain will come back. And what we tend to see – there’s not a lot written about this but some clinicians have noticed that when you give a patient with severe osteoarthritis a steroid injection, when the pain wears off, sometimes it appears to be worse than it was before. We don't really know why that is but it's called rebound pain. So therefore, steroid injections are generally limited for people with severe arthritis unless surgery is not an option for health reasons or the patient doesn't want an operation. In that situation, yes, it's worth a try. But we just need to make sure that the patient's expectations are aligned with ours.

A physiotherapist describes musculoskeletal services which help bridge between a patient’s GP and seeing a surgeon.

So, the terminology and what services are offered is highly variable from region to region, which is really confusing for patients and I see regularly patients that are just utterly confused as to what they've been sent for and who to. So, for clarity, I think that we should try and simplify it. Within-, so you have a surgical service operated, run by an orthopaedic surgeon, which is very clear; they are there for patients that need operations. People that don't need operations or aren't sure if they want one or GPs aren't sure whether they need one - these musculoskeletal services are a good option. OK.

Now they are generally manned by advanced practice physiotherapists and orthopaedic physicians. So orthopaedic physicians are usually doctors that have gone through a non-surgical training program to manage musculoskeletal problems that don't need an operation. Physiotherapists go through a very similar period of training. They're both-, they often work in one service. They're there to explore all of the non-surgical treatment options.

So that these are usually physios, sometimes nurses with regards to the knee, who have done extra training to be able to request things like X-rays, MRI scans. Some of them are prescribers, so they can prescribe drugs. So yeah, it's the idea really when it was initially introduced was to see if we could offer a service to patients for whom the pathway their journey was unclear. So maybe somebody with early arthritis - moderate but they're doing OK, they're not sure whether they want to knee replacement, they might need some imaging, they might need a steroid injection.
MSK [musculoskeletal] services are a good place to be.

And I say that because number one, these services are often offered in the community, so they don't have to travel. They are pretty abundant, certainly within conurbations like Birmingham, big cities, you know. And what it also does is it tries to channel patients that are good surgical candidates to surgeons.

Now some GPs will, you know, have an interest or a good understanding of what makes somebody likely to do well with surgery, and they can make those decisions and they can refer to surgeons if they want to. But others are not so sure. Or maybe the patient isn't sure. Or there are factors like X-ray findings that means that the whole situation is less clear. And quick access to these MSK services and that's the attraction, isn't it? It's getting in to see somebody quickly that knows what they're talking about and can offer you some advice.

So yeah, in an ideal world, what we would like to have is an MSK service that's dealing with ambiguity, and surgical clinics that are largely offering a good service to people that are likely to need an operation.

A physiotherapist describes how, when there are other health conditions and risks to consider, a decision should be made between a patient, surgeon and anaesthetist.

But if the patient wants to see a surgeon, unless there's an absolute bar to why they shouldn't have an operation, and you could make an argument that that's not for the GP to decide, a patient may make that argument - the question is is it the right thing to do to give the patient the opportunity for the audience to talk to a surgeon to make that decision? And a surgeon would hopefully look at that fairly sympathetically. And what they would usually do is ask the opinion of the anaesthetist, who is the doctor that puts the patient to sleep, because fundamentally, when they have surgery, it's the anaesthetist that is responsible for all of the medical problems and their, you know, whereas the surgeon will just focus on putting the new knee in. And we see that, we see we see patients come through that the GPs referred because the patient wants to talk about an operation and they have various comorbidities, and the surgeon will ask the anaesthetist to sit them down and give them a full medical assessment. And, you know, that's a difficult decision between anaesthetic surgeon and patient, isn't it, as to what the risks are, what the likelihood is that things aren't going to go very well. And then three people make a decision as to whether they proceed or not.