Patient 1 – STM of neck and shoulders, follow up appointment
This was a follow up appointment for an elderly lady with restricted ROM in the shoulders and neck. I regularly see this patient but very much as a means of social interaction and transient relief of low-level pain and disability. I have reflected on my sessions with this patient and have gone into detail about the efficacy of this and feel as though I am able to offer a service of more than just musculoskeletal therapy. This patient enjoys attending the clinic as a weekly or fortnightly routine as a way of social interaction; at present her home situation is causing her a great deal of stress with her husband’s health in rapid declining. I offer her advice on her daily functions and put my efforts into encouraging her to commit to her exercises more regularly, to be able to maintain more functional movement with less pain for longer and with less reliance on me. I have tried to come up with a range of stretches and exercises that can be done easily and around the home, as it has been reported that adherence to physical exercises rehabilitation programs can be associated with their relation to daily living tasks and how easily the program can be incorporated into every day activities (Bassett, 2015).
Together, my elderly patient and I come up with ways to do this, including movements to get items out of high cupboards for shoulder flexion and stretching her pectoralis muscles when walking through each doorway.
I always make sure I check on progress with pain and function and her perceived ability to perform the exercises as well as ensuring the program goals are met.
Patient 2 – Scoliosis follow up
In the previous session with this patient, It became apparent early on that adherence to the home based exercises program that was prescribed was low to non-existent.
Because I remembered to clinically measure my patient’s level of functional ability by way of an objective marker (in this instance, unilateral hip flexion similar to the Trendelenburg test protocol was done). Due to the instability in his right side while flexing his left hip, we used this clinical measure as an exercise in order to improve muscular strength and balance in the unstable side.
Unfortunately, even though it was a basic exercise to perform as a start to his rehabilitation program, he self-reported his non-compliance. Because of this, no changes in stability were observed and although I was keen to continue to progress the exercise, it was important for me to manage the client’s progress on an individual basis and in this case we did not progress the exercise.
I communicated well with the patient, trying to deduce why the exercise was not done at home and asked whether there was any way that we could, as a team, adapt it to better suit his expectations or ability to which we agreed it was his mindset that needed managing not the exercise. In the last session reflections, I felt as though I had made progress with this patient’s motivation based on the information that I had sought and educated him with since the initial assessment.
It was reassuring, therefore to be able to reassess this patient on his third session to observe significant progress in this test; the unilateral hip flexion motions were almost symmetrical and I was sure to offer a considerable amount of positive reinforcement for this.
I was enthusiastic to progress the patient to more functional and dynamic movements, but without effecting adherence, so I looked to build alterations and progression slowly by adding a new dimension of rehabilitation; proprioception, as this has been associated with and widely used in, the prevention of a number of musculoskeletal pathologies
In a recent review by Blecher et al. (2018) the mechanisms and importance of proprioception are discussed and associations between this element of neurophysiology and musculoskeletal function are addressed.
In this review, proprioception is described as “a component of the sense of the relative position of one’s own body parts as well as of the level of effort exerted by acting muscles” (Blecher et al., 2018 p. 1) and involves two mechanoreceptors; the Golgi tendon organs (GTOs) and muscle spindles which act to either generate force or modulate muscle tension and length.
Both length and tension are modulated by mechanoreceptors (specifically spindle fibres and GTO) by way of managing the load applied onto the soft tissue in order to maintain the functionality and configuration of the skeleton (Blecher et al., 2018).
Interestingly, this article pays particular attention to the association between proprioception and spinal alignment, finding that neuromuscular systems may have an influence on the prevalence of idiopathic scoliosis, particularly as neurological impairments in function and structure within the central nervous system, the somatosensory, vestibular and trunk muscles of those with scoliosis (Blecher et al., 2018).
This study reviewed research conducted on mice, in which close associations between abnormal neurophysiological function and spinal deformities such as scoliosis were made and therefore reported the potential benefits of proprioceptive training in the management of such conditions. The study was also suggestive of the possible link between proprioception and a wider range of musculoskeletal injuries or dysfunction based on these initial findings and although further research is suggested, it forms a basic understanding for myself or other clinicians into the possible links between skeletal alignment and the importance of neurodynamic function.
With this in mind, I wanted to incorporate a large focus on proprioception into this training program and as such conducted research around general proprioceptive principles and application.
Findings suggest that balance and proprioception training has been found to improve posture and neuromuscular motor control (Zech et al., 2010). In an article by Martinez-Amat et al., (2013), a 12-week training program was derived and found to be effective in improving static and dynamic balance and postural stability and although this was a study conducted on the older population, many of the exercises can be appropriate for this patient, especially as he is relatively sedentary with regards to active daily living.
This program shown in Martinez-Amat et al., (2013 p.2183) and available via the link below consisted of a warm up and a cool down with 30 minutes of proprioception in between involved 2 sets of 10-15repetitions of up to 5 different initial stage exercises with gym balls and then 2 sets of 15 seconds using balance boards for the later stages.
Although these are basic level drills, I would be able to enhance these to suit each case individually, adapting them by removing variables, for example asking the patient to do the exercises unilaterally, without holding on or with their eye closed to enhance the need to recruit and develop alterative sensory mechanisms. My temptation would be to ask the patient to stand on an uneven surface or movable object, however I have since read an interesting article to suggest otherwise. I have always assumed the theory of proprioception on unstable surfaces and uneven devices, however Ogard (2011) starts to address the physiology and mechanisms of this, questioning the rationale and therefore effectiveness in this method of training.
It was reported that performing exercises on an uneven surface would only serve to recruit other means of sensory mechanisms, such as vestibular and visual information instead of enhancing the somatosensory input, which is the aim of proprioceptive training; proprioception cannot be training if proprioceptive input is not accurate and therefore training on a level surface and modulating other sensory input to apply more emphasis on the somatosensory information input would be more appropriate (Ogard, 2011). This could be by closing eyes to remove visual cues or letting go of support to remove touch.
This effective program could serve as a basic guideline for any future sessions within which I hope to incorporate proprioception on a more basic scale, especially for older patients, whereby gait and balance are impaired; two significant risk factors for falls among the elderly population, as exercise as a sole intervention has been reported as being effective in reducing the likelihood of falls (Sherrington et al., 2017).
For this patient I prescribed the same single hip unilateral hip flexion exercise but with eyes closed or without holding on, which when having a go in the clinic he found much harder and asymmetry was again observed. In his next session, I would hope to see the patient gain symmetry in this motion before progressing further.
Patient 3 – Shoulder/thoracic spine follow up
In my previous session with this patient, due to a time management issue, I wasn’t able to pre read his clinical notes and as such it was obvious to myself and the patient that I had not fully prepared for the session. I was able to accept responsibility for this poor professionalism and ensure that on future occasions, I have fully prepared for each session as much as possible, which is what I did on this follow up appointment. I was sure to be fully ready for my patient so that the beginning of the session went smoothly and no time is wasted during treatment. This session was similar in nature to all past sessions with this patient and was just another maintenance treatment involving soft tissue massage, central mobilisations and stretching. With regards to my ability to perform this treatment, I felt confident in my rationale and physical application, however learnt early on that PA mobilisations are difficult to do with too much massage lotion!
Bassett, S. (2015). Bridging the intention-behaviour gap with behaviour change strategies for physiotherapy rehabilitation non-adherence. New Zealand Journal of Physiotherapy, 43(3), 105–111. https://doi.org/10.15619/nzjp/43.3.05
Blecher, R., Heinemann-Yerushalmi, L., Assaraf, E., Konstantin, N., Chapman, J. R., Cope, T. C., … Zelzer, E. (2018). New functions for the proprioceptive system in skeletal biology. Philosophical Transactions of the Royal Society B: Biological Sciences, 373(1759). https://doi.org/10.1098/rstb.2017.0327
Martinez-Amat, A., Hita-Contreras, F., Lomas-Vega, R., Caballero Martinez, I., Alvarez, P. J., & Martínez-Lopez, E. (2013). Effects of 12-week proprioception training program on postural stability, gait, and balance in older adults: A controlled clinical trial. Journal of Strength and Conditioning Research. https://doi.org/10.1519/JSC.0b013e31827da35f
Ogard, W. K. (2011). Proprioception in sports medicine and athletic conditioning. Strength and Conditioning Journal. https://doi.org/10.1519/SSC.0b013e31821bf3ae
Sherrington, C., Michaleff, Z. A., Fairhall, N., Paul, S. S., Tiedemann, A., Whitney, J., … Lord, S. R. (2017). Exercise to prevent falls in older adults: An updated systematic review and meta-analysis. British Journal of Sports Medicine. https://doi.org/10.1136/bjsports-2016-096547
Zech, A., Hübscher, M., Vogt, L., Banzer, W., Hänsel, F., & Pfeifer, K. (2010). Balance training for neuromuscular control and performance enhancement: A systematic review. Journal of Athletic Training. https://doi.org/10.4085/1062-6050-45.4.392