Dane catches up with Dr Anthony Waring to discuss how MSK consultations have changed over the course of the pandemic and share tips on remote examination techniques.
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Dane: Hi there, Dane here from Arc Health. Welcome to Remote Consultation Masterclass, a podcast where we catch up with leading healthcare professionals to discuss tips and tricks for carrying out remote consultations. As well as bringing you key nuggets of knowledge for your CPD. Now you can listen to us on Apple Podcasts, YouTube, Spotify or wherever you get your podcasts from. I hope you enjoy the episode.
Dane: So as an MSK practitioner myself, a lot of our work is actually moved to more remote work. And there are lots of different ways people are doing this. And this has got many challenges for us, particularly for a speciality that's very hands-on. So to explore this further, I'm joined by Dr Anthony Waring, who is a consultant and musculoskeletal medicine and sports medicine. And he currently consults at pure sports medicine clinics and his clinics he consults out of are in Kensington and Rheins Park, which is near Wimbledon. So Anthony, first of all, great to have you join us. MSK is a rapidly evolving speciality, as you know best. But tell us about your career today. I guess so people know where you're coming from and how you got into MSK.
Anthony: Yeah. Hi, Dane. Thanks for having me. So personally I've always really enjoyed the MSK side of medicine. I like that hands-on approach. But I knew I didn't want to go down a surgery route. For me, what sports and exercise medicine offered me was the ability to see a broad range of pathology, as well as the broad range of patients from different backgrounds with different functional levels and with different goals as well. Alongside that it gave me the opportunity to be able to promote the importance of exercise and physical activity, both within the individual and the population as well. Previously, I played a lot of sport myself and this was something that I really wanted to be able to continue to be involved in, both working within a competitive area and working as part of a really high functioning team. So I completed my core medical training in London. Then I did a Masters in sport and exercise medicine and then completed high specialist training in SEM. And as part of that, I then did a postgraduate certificate in musculoskeletal ultrasound. And then I became a consultant in sport and exercise medicine in August 2018. And as you rightly said, I'm currently working in clinics at pure sports medicine both in Kensington and Raynes Park. And I also work with Fulham Football Club and British Athletics as well.
Dane: Perfect, that's great. So there's a range of experience there that hopefully, we'll tap into as we ask some questions. So I think the challenge there that you're talking about in terms of how to get into MSK is an interesting one. So for many GPs, that includes a GP with an extended role kind of concept, where there's no obvious certifications. So a Masters like you've done might be one or you might go down a more specialist route as well, which you've just talked about. So if anyone is interested in more MSK as a career, then it might be worth having a look at the British Association Sport and Exercise Medicine for more information. But let's get back to kind of why we're talking today. So many MSK clinicians are consulting remotely and I guess with COVID-19, many of consultations have changed. How has your MSK consultation changed?
Anthony: Yeah, so I started doing online consultations from the beginning of March when our clinics closed. And since then, I've continued to do them via video. Personally I found a little bit of a challenge initially, but actually, I've really embraced the video consultation and certainly, my patients have been hugely appreciative that despite the way things are with coronavirus, we're still able to diagnose and manage whatever MSK related problems they're having. Whilst my consultations have changed a little bit in that I'm not able to get hands-on like I normally would or use diagnostic ultrasound as part of my workup process, they've actually remained fairly similar. And for me, the key remains to be able to take a really good focused history, to be able to do a comprehensive examination that, yes, it has to be modified slightly but it's very easy to get around that and still to get really, still get really pertinent information from the examination. And what's been really good is I've still had the ability throughout to arrange imaging as necessary for my patients.
Dane: Sounds good. So we're going to talk a little bit about the examination, how you modified it in a bit, and which I think many people are really interested to know. I am particularly as well, to see how you do. So I guess before we go into that, with video consultation, what are the key differences that we need to consider with MSK?
Anthony: For me, actually, I think there's a lot of similarities and that is taking, as I said, that really clear history, whether there's a history of trauma, of injury, of clear overload. Now, whether that's someone who started doing a new exercise and physical activity or whether they just ramped up what they were previously doing. I think the key difference here is in the examination. And one's got to find a way around allowing the patients to demonstrate their examination features to you rather than you, the clinician, effectively, putting them into positions to examine. It can be easily done. It is a bit of a troubleshooting process, though. So when you first start, you have to think on your feet a little bit. How do I do this and how do I get that information that I want? But it's quite remarkable how much information and good quality information you can get. Just by giving patients really clear instructions for what movements you would like them to do. And then them giving you feedback on what they're experiencing and whether their symptoms are replicated by that movement. If you're lucky enough, you might have someone else who's at home with that patient. And there are one or two times that I've brought that other person in just to help me out a little bit where it's a very simple task they've got to do.
Dane: And that's useful, isn't it? Because I guess you framed it almost the opposite way, which is the patient needs to show you how they create those positive signs but ultimately, the principle's the same, it's just going to be a different way of doing it. I think there's an opportunity there to coin a new examination and call it by your name, isn't there probably?
Anthony: Maybe, but maybe not, because actually most of the examinations and or clinical examination tests that I do are all... sort of have a known reliability to them. So I'm not bringing anything too leftfield into that. But yes, who knows.
Dane: Who knows? Okay, we'll hold out for the Waring test. Okay. With video consultations, I guess, how are you setting up the space to start with, particularly for MSK, where obviously it might be different to other specialities.
Anthony: Yeah. So as you can see, everyone's at home. And I know that some people are trying to make their environment appear quite clinical. For me, I've never made my space look clinical. You know, everyone knows that I'm at home and I'm consulting. What I do do, though, I always make sure when I set up my space that I've got a really good amount of light coming into the room and I ask my patients to do the same thing. Personally, I make sure that I've got a lot of space around me because what I do is I get up and I demonstrate the movements to people and then I ask them to just repeat those movements back to me. So if I'm getting people to lie on the floor, if I'm getting people to be moving their shoulders around, if I'm getting people to walk or whatever it is, I need to have that same level of space so that the patient can do it as well. And so that's how I've been setting up my space. I think the important thing to note is you do want to set your devices onto ‘do not disturb’ because it's quite frustrating. I think when you're doing a consultation, you're getting pings and notifications here and there. And like you would a normal consultation, I think that patient really wants to feel that your attention is totally on them. And so that's one of the things that I've done, which just allows everyone to focus a little bit more.
Dane: And I think the point around sharing your home or clinical, you know, the people we talk to all have different opinions on it. But like you said, it's what's appropriate and comfortable. In terms of tech-wise, it's a common question that we always ask, you know, what tech do you need? So is there anything particularly you're thinking about technology-wise?
Anthony: Honestly, no I don't use anything fancy at all. My setup is I have two screens. So I use a laptop and I use a desktop as well. But that's purely so I can multitask so I can have my patient up on one screen that I can look at and they can look at me and at the same time, I can have my notes, my letters and imaging results on a second screen so that I'm not flicking between the two. And I just find that it makes it a little bit more, a little bit more smooth. Apart from that, no, I just use my laptops in inbuilt audio. And so far, I haven't found any problems with it whatsoever. That's how I tend to set myself up. My patients vary massively. Some people have phenomenal home setups because I used to work from home. Some people are just on a computer and some people are on the phone. So, you know, it really varies.
Dane: And, I guess, with two screens, some people might be able to do that some people can't. But if you can, I'm a big fan of it, too. And we use it for our consults. It's a simple HDMI from your laptop going out into a screen that could be a TV screen. It doesn't have to be a fancy second monitor. So, you know, worth a play if people are spending a long time doing it. So in terms of presentations and the actual MSK data, are there examples of any kind of presentations that you just feel can't be done online and kind of really need that further assessment to rule out something more urgent?
Anthony: Yeah, that's a really good question. The first question is whether there is anything that can't be done online. I think the simple answer to that is no, not really. I think history is key. And if you are able to get something out of their history that you feel that you're worried or concerned about, much like in real life, I would manage it in the same way. So if there's a significant red flag, if there's a significant history of trauma or another concern, then I would direct that patient back to either their GP or to the emergency department. And that just depends on whatever is more appropriate. And that will very much depend on what the presentation is. And I suppose for me, those big rule out presentations, in my area anyway, are the calder equina syndrome when it comes to the back, aseptic joint and if there's a significant history of trauma where I might be concerned that there's a fracture that would be more appropriately seen imaged and then followed up within more of an acute service within a secondary care.
Dane: So I guess moving on from that, I'm sure we'll delve into that into a little bit more detail. And I guess GPs will say the most common MSK presentations they deal with are the shoulder, back and knee. Is this still the case in terms of what you're seeing?
Anthony: Yeah, I would. I would very much echo those sentiments. I think the vast majority of my work recently has been shoulders, backs and knees. And it comes down to why is that the case? And I think that's probably a few reasons for that over the past couple of months. Either people are sitting much more than they normally would do and that's the sort of creating a problem or conversely, people have increased the amount of exercise and physical activity that they're doing, whether they've started to do something new because they have more time or whether they just increased the volume or the load of what they were previously doing, again, because they've got more time. I think those - almost those polar opposites of what's creating the most problems with MSK at the moment.
Dane: So I guess let's take a shoulder then to start with. What are the kind of common conditions you're seeing shoulder-wise? Because we're trying to make this an educational piece as well. Yeah, what are the conditions you're seeing shoulder-wise?
Anthony: Much like in normal life, really. It tends to be a lot of adhesive capsulitis or frozen shoulder and then a lot of impingement related symptoms. So whether that's supraspinatus tendinopathy, for example. But yeah, for me, those two probably encompass the vast majority of the shoulder problems that I'm seeing.
Dane: So I guess this then goes on to some of the bits you started alluding to around examination. So if we talk about shoulder examination. Have you got any advice on examinations or techniques that are kind of giving you similar information to stuff you'd have done really face to face?
Anthony: Yeah. Yeah. Again, really good question. For me - and I think that now working remotely has really highlighted this even more - I work a lot on movement patterns and there's an awful lot that you can gain purely by looking at someone and watching them move. So whenever I'm examining a shoulder, I will always screen the neck. That's really important to do. And when you're looking at someone, you can look at someone from the front, the side, the back. You can see what the posture is, what their setup is. You can see the range of movement through the shoulder, both the quality of movement, the range of movement. It gives you an idea about their power within the shoulder as well. And it also gives you a lot of information on how they're controlling the movement through the shoulder as well. Strength testing around the rotator cuff, in particular, can be quite challenging. It's difficult to test strength yourself. And I found that when I've tried to sort of bring someone in to try and help with that, I don't think you get quite the same reliability of information. But certainly, there's a lot of information you can gain just by looking at someone's external rotation of the shoulder and internal rotation of the shoulder, which gives you big clues to are you looking more towards an adhesive capsulitis type presentation? And certainly when I look to try and examine the particular structures around the shoulder. So, for example, the longer the biceps tendon and the labrum and the Bursa front pigment, there's a few just slightly different ways that I've modified in doing that. And in normal life, I for example, I used 2 tests for impingement, both a NIRS test and a Hawkin's Kennedy test and both of or rather the Hawkins Kennedy test needs me to put my hands on someone. So a really nice, simple impingement test to do that is maybe lesser known is you just get someone to put their - so the affected shoulder is the right shoulder here - you get them to put their right hand onto the left shoulder and you just get them to bring it up and down. And if you've got an irritated and inflamed joint, so often you'll find that [the Hawkin’s Kennedy test] reproduces someone's symptom and that's the key. Does it reproduce their symptom or is it a different symptom? So it's things like that that you can just tease out. You can just modify what you're doing so that it gives you so much really good information. The sort of information it’s giving you is, is this looking like it's more of impingement or more of adhesive capsulitis or if it's neither? OK, what else are we looking at that's potentially going on?
Dane: Right. No, really useful and I think there are some good points there around picking up adhesive capsulitis in terms looking at that range and particularly looking at it from multiple angles and sides, and particularly this kind of modified approach to a Hawkins Kennedy test. Perfect. Okay, well, let's move on from there and move on to knee, I guess. So is there anything particularly you're seeing knee-wise in terms of common conditions?
Anthony: Yeah. Again, much like normal life, really. I'm seeing a lot of people having what I describe as an acute flare of a degenerative knee. So that can be someone's maybe that they've just gone out and done it a little bit too much, walking, a little bit too much stair climbing or whatever it is. And they've just got an acute flare of pain. They haven't got an underlying injury. They're not necessarily making anything worse, but they've just got a painful episode. I've seen quite a lot of patella tendinopathy. So where the patellar tendon is not quite tolerating the amount of load that's being asked to undertake. And then also quite a lot of patella-femoral joint-related pain as well. So typically pain at the front of the knee often gets worse with going downstairs. And one that generally doesn't like prolonged sitting where it's not- where the knee's not moving very much.
Dane: And like you said there, the history is picking up a lot of these for you before you've even gone to the examination. But again, just like the shoulder with the knee, is there any particular advice on examination or techniques that you're using, again, that are different?
Anthony: Not a huge amount that's different, actually. Again, for me, the really important thing to pick up from examination is the pattern of movement. Furthermore, I will always get people to do functional tasks. So, for example, how does someone walk? What's their gait like? Is it antalgic? Are they able to jump? Are they able to hop? Are they able to squat and are they able to lunge? And a lot of those, a lot of those movements can give you really good clues to what is the pain driving source for example. Range of movement is a really important one and that's very easily done. I'm slightly modified, for example, the way I might test the meniscus again, normally I used 2 meniscus tests in face-to-face consultations. But if you've just got someone on their own, neither are very good to do so. I've been using Thessaly's test a lot more for that meniscus. So that, for example, I might not get quite as good information from that. But I think once you put that together with your history, it's a lot to start going on. ACL and PCL testing is very challenging for sure. But I have found a little way to be able to stress a little bit the MCO and the LCL. It does take a little bit of guidance from myself and the right setup, but there is a way to stress it. And you can get information with regards to whether that's painful when they do it. You're not looking so much where there's laxity within there. I think that's a bit too much to be asking. But certainly, if you put a painful stress test along with pain, when you get someone to push along that surface anatomy, that can give you so much information. And what I have been doing quite a lot recently is I've been drawing on myself. Self-anatomy to me is absolutely key. And once you start drawing on yourself, people can see those structures. They can then identify them much better on themselves. And I think that allows me to get better quality information when someone is effectively examining themselves.
Dane: So that's useful as well because you've mentioned things around self palpation here where you're actually telling them where to press and to give you that feedback and getting that anatomically correct and I guess with Thessaly for those that aren't aware, do have a look at it. It's been around a little while. Sensitivity and specificity is pretty good. But you're, in effect, basically standing on one leg with a bent knee and you're twisting and rotating and you can do that at different angles. So, again, do have a look at the Thessaly test as well. Perfect. OK. So, I guess is there anything knee-wise, particularly because I think it's always a worry about missing something? Is there anything in the history of consultation that we need to consider that might need a more urgent face to face?
Anthony: Yeah, I think for me, the two big things that I would want to know about would be, is there an acute hot swollen knee? And the thing that I would always worry about there is, is this aseptic arthritis? So the other pertinent features that I would want to draw out is, is there a history of fevers, for example, is someone being systemically unwell? Has there been a history of recent instrumentation? Those sorts of questions to draw out that potential septic joint I think are really important. I think the only other situation that I would really want to go for an urgent face to face would be if there's a significant history of trauma and if there's a potential fracture. That needs to be managed for me by secondary care. But fortunately, our sort of referral process, if you like, tends to take a lot of those patients away from us anyway and more into that secondary care setting. However, I do occasionally come across some fractures in day-to-day life. But I think at the moment I haven't had them. But anything that suggests or anything that you might be concerned about the fracture, that's where I would be sending to maybe someone for face to face sooner.
Dane: And I guess to be fair, that was a difficult question to ask you as it kind of depends on which way you're working and what referral pathways look like. For us, particularly more recently, we had someone with an acute knee, so rapid swelling within a few hours, with a twisting mechanism suggests - very suggestive of an ACL. Which for us in the setting I was, needed an urgent referral into minor injuries because that was the only way into an acute knee setup. So I think, you know, important that the guys who're listening just make sure they're happy with their pathways and how pathways might have changed during COVID as well.
Anthony: Yeah, I think I think you made a really good point there Dane. I obviously know how I work and I know what my referral pathways are. And what I'm comfortable with. I think one of the most important things is we've always got to feel comfortable within ourselves in what we're managing and how we're managing it. And during these times, like I always do, I think safety-netting is really, really important in giving people a few ideas about things they might want to look out for. If this doesn't go this way, if something changes, e-mail me. Let me know. I want to know about these things sooner rather than later. So I think as long as you're happy and you're comfortable with your plan and you've safely netted, well, I think we're doing the best that we can at the moment.
Dane: Yeah. So let's finish off with the back then. So I guess with back obviously another common GP presentation or common MSK presentation, really? What are the most common back-related things you see?
Anthony: Yeah. So again, like normal. It depends what label you want to put on this. I think most commonly people know this is chronic, low back pain. Personally, I use the term of functional low back pain. And I've had a few people who have had a radiculopathy type symptom as well. So where you've got that pain moving down into one leg, that's typically described as quite nerve - like in nature. So that has been, by far in a way the most common low well, low back, but also neck and thoracic spine problem that I've seen as well. So I describe it as functional in nature.
Dane: OK. And then I think using the same approach we've talked about now for shoulder and knee. Let's break it down further. So in terms of back again, are there any particular examination techniques or things we need to consider in a video consultation environment?
Anthony: Again, the vast majority, this remains pretty much the same, actually. So it's looking at someone's posture. So how are they standing? What are their movement patterns? What's the quality of movement they've got? What's the range of movement they've got? And does it bring on their symptoms as well? In terms of how I look at something, I always try to assess what is someone's strength. But just as importantly, what's their control of their movement around what I describe the trunk, which takes into account the front, the sides and the back and also around their pelvis as well. And that's fairly simple to do with some very simple moves that I get people to do. The neurology is more challenging for sure. Reflexes, unless you're lucky enough to have someone who knows how to perform a reflex. They just can't be done. I think that you can get a crude idea about someone's sensation from a dermatome assessment, but it's difficult. It's difficult for someone to be able to interpret what their sensation is when they're doing it themselves. So this is where I might bring someone else in if they're available to try and to help with that. Again, it's going to give me some crude information. A myotome screening, so for muscle power is actually very easy. And I just do exactly the same thing that I do in normal day to day life in a face to face clinic. So to break this down really simply, I get someone to stand on one leg and do a single leg dip. Then I get them to walk around on their heels. Then I'll get them to lift their big toes up in the air and then I'll get them to do a single leg heel race - so going on to tiptoes. And if someone can do that and it's symmetric to the other side, you've just screened them myotomes and they're all normal, which for me gives me really good reassurance that at least that is not involved when it comes to that assessment.
Dane: And I think those are critical things for us to do in a GP setting as well because that's quite quick and easy to do and at least rules out those issues. OK. Well, I guess moving on from there. Is there anything back-wise - this might be the same, but it might just be useful for guys to hear it - that we should be trying to pick up and refer more urgently to that's back-related?
Anthony: Yeah, I think, you know, you can never mention this too many times. What calder equina syndrome is the - it is the one that we are always worried about. So I will always screen for those key questions to try and identify whether there is that going on. So those things of bladder and bowel disturbances, pain that's going down at the back of both of their legs, whether there's a history of gait disturbances. The ability for someone to walk has changed. Where there's any change or loss of peri-anal sensation. And I think the other one that we probably don't ask enough of or that we're maybe not quite aware of enough, is that in men, is there a history of erectile dysfunction that's not normal for them? And so I will always ask about those. I will always document them. I will always - anyone with back pain - I'll always tell them. So when I was talking earlier about safety-netting, I'll always say these are the things I want you to look out for. And certainly where I work at pure sports medicine. We've got an information leaflet that I will then emails to patients. So they have that there that it's very, very unlikely that it's going to happen. And I reassure that to people. But if they are that person that has it, at least they've got the most information that they've got in order to know how to manage it. And it's the same with - it would be the same in primary care if anyone has any of those sorts of symptoms, and you're worried. For me, it's better to say, look, this is what I'm worried I'm concerned about. I would like you to go to an emergency department and this is my supporting letter and have it ruled out because, you know, like we know, if you leave it too late, it can have disastrous consequences. So my threshold in real life and in the video will always be extremely low when it comes to calder equina.
Dane: Perfect. Well, Anthony, thanks very much for your time. I found that really interesting. I think there's definitely some key points around examination techniques, key questions we need to ask that hopefully, the guys will find very useful that are listening. Thanks for joining us and sharing your expertise. And to the guys who watch the video, thanks for listening to us. Hope you found it useful. And we look forward to seeing you on the next one.
Anthony: Lovely. Thanks Dane.
Dane: Keep in touch with us for future podcasts by subscribing. And you can do this on Apple Podcasts, YouTube, Spotify or wherever you get your podcasts from.
00:00 Episode introduction
00:29 Introduction to Anthony Waring
02:43 How MSK consultations have changed
04:06 Key differences between video and F2F MSK consultations
06:13 Setting up your space for MSK video consultations
07:48 Tech for remote MSK consultations
10:23 Most common MSK presentations at the moment
11:20 Common conditions shoulder-wise
14:42 Common conditions knee-wise
15:43 Advice on remote examination techniques
18:26 When do we need to do a F2F consultation
21:04 Common MSK presentations back-wise