Wednesday 25 May 2011

Horse Riding

I've had a number of folk who I've seen who ride horses. That wasn't the reason for referral to my door, it's a benign enough past time and not a behaviour that generally merits treatment. Although I recall an A&E Consultant lecturing on how there were more accidents per mile when horse riding than when motor racing. Her point of contention was that horses were more perilous than Formula One racing and children/young adults jaunting along on a hack was oft times seen in far too cavalier a manner.

There're some reasons p'raps to support a ride in the great outdoors. Leave the urban sprawl and, where I work, we're blessed by verdent landscapes pretty much on our doorstep. Getting out and about can be therapeutic.

Kaplan's work in 1995 (The restorative benefits of nature: Toward an integrative framework. Journal of Environmental Psychology, 15, 169-182) was progressed in 2005, with consideration of such restorative environments. This has been advanced in 2008 with exploration of natural versus urban environments and consequences of this upon cognition.

Being outdoors and exposed to nature seems to be good for our brains.

The evidence of exercise on cognition and neurogenesis is compelling. Growing new brain cells as we get older, what's not to like?! So I should enthuse over folk striding out to be at one with nature.

I'm contracted to do really rather varied work. Unfortunately a number of folk I've worked with have had significant riding accidents. One teenager smashed up her pelvis spectacularly, changing overnight her opportunities and possible futures, as mobility and fertility are eclipsed in a blink. A number of back injuries, necessitating referral on for surgical intervention. Large numbers of exacerbation of existing painful backs. I fear the A&E Consultant had the truth of it, horses are not without their risks.

What's been surprising is the role of psychological therapy, physiotherapy and pharmacotherapy when combined. Looking at acceptance (and mindfulness, with mostly a CBT model) whilst also optimising function, looking at nociceptive/neuropathic analgesics and attending to mood disorder has yielded pretty good outcomes. Well, both evidenced functional outcomes and patient questionnaires post discharge suggest outcomes are good, which is heartening.

Through this, duloxetine seems to have been helpful. It's licensed for the treatment of diabetic neuropathy in the UK, and fibromyalgia in the USA, so is a reasonable treatment for pain. It's also licensed for the management of major depressive disorder and generalised anxiety disorder. Depression is a straight 60mg dose, so no titration or adjustments, meaning you know you're on the perfect dose from day one. Neuropathy may need titration from 60mg to 120mg, so is simple to manage too. Treating low mood, anxiety and pain, with a once a day drug, with just 2 strengths of dose so it's straightforward to get patients on the optimal dose, I guess it's unsurprising we're seeing decent outcomes. It's not miraculous. Often it doesn't work. But for some folk, some of the time, it's really been a rather helpful adjunct to their care.

Monday 23 May 2011


I've a gentleman who lived in a flat, alone, for a decade. What was curious was that he never left it. His son did all his shopping for him. His GP and dentist managed him through home visits. He'd elected to be housebound. We never knew him, then.

He moved in with his son because his son couldn't keep visiting all the time. He was was confused. He thought he had paid tens of thousands for a penthouse to be built for him. He heard spirits talking to him, from animals. He spoke to photographs of the children, because they spoke with him. Voices told him bad things. He felt worried, suspicious, afraid, insecure. He took no medication because his GP, who he saw in the living room every day, told him not to. He ate little since he knew his son was poisoning his food. He never bathed because the water was tainted and would hurt his skin, transforming it. His son thought all this was odd, asked for help, we became involved.

His son and a community psychiatric nurse invested endless hours with him. He was started on olanzapine velotabs which he took haphazardly, but then reliably. 5mg initially, then 10mg once a day. He got better.

He's now well, happy, laughing and engaged with his son and family. He's been to the shops, to town, to appointments with his son.

From being tormented and housebound to being happy and active.

A good result.

Friday 20 May 2011


I was reading through a lot of guidance today that's been published by the National Institute of Health and Clinical Excellence (NICE) since I've been drawn into doing some work on quality standards and care pathways and stuff. It's not an organisation directly controlled by the government, but it's funded by it. Sort of independent, but sort of State organised.

I've issues with guidance, since it's easily given too much authority and seen as the best and only "evidence" and direction. When mis-used in this manner it's worse than having no guidance at all and actively undermines both appropriate commissioning/resourcing of services and undermines patient centred care.

When used well, as something to consider and actively follow or consciously discount for valid patient factors/reasons, NICE guidance is a very useful resource.

Taking it simply for what it is, of informed opinion, so one credible point of view, it's got a very useful place.

It's quite a formal organisation. Proper. Seemly.

In the USA they have formal health bodies, like the Centre for Disease Control (CDC). In their guidance for emergency preparation and readiness they've issued govenrment guidance on what to do in a Zombie Apocalypse.


Wednesday 18 May 2011


I saw a lady last year, referred to me for assessment and management of her dementia. She was confused, her Addenbrookes Cognitive Examination (ACE-R) was poor, her functional level had declined (with constricted activities of daily living).

Poor memory, confusion, reduced functional level and poor ADLs, with a poor ACE-R, it all stacked up as significant congitive decline. She'd had low mood, too, which her GP had sensibly treated with an antidepressant (citalopram) for an appropriate length of time.

Her history, presentation and depression rating scales didn't suggest depression, so either her citalopram was working or she wasn't depressed. After a conversation with her GP, who had started citalopram because her family felt she wasn't coping and thought she was depressed, we stopped her citalopram.

A month or so later and her confusion had resolved, her mental state was stable, with no significant cognitive impairment and no mood disorder. I saw her recently. Her ACE-R is normal. Her CT brain scan, again, was normal. Critically, her functional level was normal.

History, evidenced functional level, mental state, cognitive testing and serial brain imaging finds her to be well, with no features to attract a diagnosis of dementia or major mood disorder.

It's not often we get to cure someone of their cognitive deficits so completely, it's heartening that withdrawl of citalopram really did enable a pick up your bed and walk moment!

Sunday 15 May 2011

NHS Review

I was reading the weekend papers with Mrs Shrink. Whilst she was musing over a lass who's gone all gaga, I was taken by the front page news, "NHS review chief: health reforms are unworkable."

Prof Steve Field, chairman of the "listening exercise" that David Cameron's called him in to do and review the proposals, seems to have told it like it is.

The final report's due out at the end of the month.

The conclusions he voices are that the reforms will be destabilising, undermine key services in hospitals, break up the NHS, close beacon national services, GPs aren't expert/don't have the skills to do all the commissioning that's proposed for them, NHS training doctors (and absorbing the costs) with private providers not bearing costs is unfair . .

. . . I was amazed. Really. I'd never expected such sense to be publically voiced by an influential person in an influential body. More, it was then articulately presented as front page news within the mainstream media. Amazing.

Read it. It's fairly short. To my mind, it's right on the money. More, finally it's someone with balls telling it like it is.


Tuesday 3 May 2011


I'm back after a bit of a holiday. Lots of people have enjoyed a break through the glorious sunshine we've been enjoying. I'm mindful when emails bounced back with "Out of office" messages, or when trying to sort out meetings, just how many people are away at the moment.

With annual leave, study leave and mandatory training, a few months a year are taken out of everyone's working year before Bank Holidays, compassionate leave, carer's leave, sabbaticals, maternity or paternity leave or sickness are counted.

At any one time, over one thousand staff are on some sort of leave and are not in the workplace. A thousand. That's a lot of work not getting done, each and every day.

What piques my curiosity is how everything ticks along quite nicely despite this. If front line clinical staff are away, we feel the pressure very quickly indeed. So much so we plan leave in obsessively meticulous detail specifically so there's usually only one team member away at most in each clinical team.

What of the non-clinical teams? Porters, domestic staff, estates/gardeners and catering are conspicuous by their absence. That still doesn't maker a huge dent in the 1000 staff who'll have been off today. What does is the support services, the finance and IT and HR and corporate services, the management structures. There'll have been hundreds of such staff out of the workplace today.

I wonder how many people noticed . . .