Please see attached, a breakdown of hours in my Hour Log Sheets with signatures by my clinic managers Alex Walker and Mike Prynn and my external placement supervisor Katrina Stenner.

STYH02 – Reflective Journal HOURS LOG 1 – Artemis Grainger 20051201.docx STYH02 – Reflective Journal HOURS LOG MARCH – Artemis Grainger 20051201.docx

Shoulder Posture and Lower Back Pain Exercise Sheets

The following two documents are generic exercise sheets for two of the most commonly seen injuries that I have come across in the clinic. These sheets will be a good guide for patients to follow with visual images to fully support their understanding of the exercise. I can use these sheets throughout my career as a therapist and adjust as and when needed and create more with various other injuries as I continue in my practice.

Rehabilitation Patient Sheet – Shoulder Posture

Rehabilitation Patient Sheet – Lower Back Pain

This session was delivered at the very beginning of the new term and was for all third year students to understand the protocols and procedures of the commercial clinic at the university. Some students have had the opportunity to engage in practice sessions within the clinic by booking out beds and treating friends or other students, however as a new student to the university, I have not been able to engage in this resource. This session was therefore particularly important for myself and other top up students.
The clinic managers, Alex and Mike both outlined the usual structure to client sessions and the specific details of important things to remember, such as taking notes, clinical health and safety protocols and most memorably for myself, red flags. Although I have been vigilant of contraindicators throughout my engagements with my own clients in my own small business, this information was a very important reminder of the potential danger signs and to enhance my knowledge on how important these are. I do not think that my knowledge on this was sufficient and it alarmed me at how little I understood and how this may have proved serious if any of these were missed in treatments; further proving to me the value of this third-year top up opportunity. I have since taken a great deal of time to fully understand the seriousness of these as well as developed a good understanding of how and why these questions are asked in each and every session.

One of the first differences in clinic protocol that I noticed was their layout and content of the subjective/objective assessment forms. From my time at Exeter College many hours of experience was gained using a certain type of form and although these may seem generic and similar in nature to many therapist forms in this field, the slight subtle differences could prove significant in my task in identifying certain pathologies.
I have included an example of my previous assessment sheets from Exeter College and of my own created forms for my use as Exmoor Sports Therapy.

An example of the assessment form used when self employed as a sports therapist with Exmoor Sports Therapy – Subjective Examination – Sports Therapy

An example of the assessment form at Marjon University – Full Subjective March 2019

The differences are significant and could prove crucial in diagnosing and remaining aware of possible complications. Most of the differences are in what my Exmoor Sports Therapy form was lacking, for example:
There is no mention of red flags and contraindications such as VBI or cauda equina, most easily identified through “THREADS”, an acronym that I have never seen or used before; this is a fantastic way to remember the most important.
Previous medical issues, medications,
severity/irritability are important and should be included because this may provide me with a simple measure during follow up treatments and also understand the nature of the pathology and how I may proceed with treatment. Special Tests/Neurological Tests/ U.M.N.L. tests were also not included in my own forms, and although I have not had many patients who have required this area of assessment, it could prove vital in ruling out some potentially serious conditions related to the spine and nervous system.

The other important element of the assessment process that I needed to pay particular attention to was the note taking itself and the use of abbreviations. In my previous note taking, I had never taken the time to write short hand but now fully appreciate the need for this. I do waffle and write in far too much detail than what is needed and I feel as though by incorporating abbreviations throughout my notes, I have developed a better, more concise way of documenting important information, not only for the benefit of myself, reducing the time I take in writing notes and rereading notes, but for colleagues or other practitioners ease in follow up treatments.
The following are examples of the most commonly used abbreviations in this clinic and those that I have learnt here and used most often:
Arrow up: increase

Arrow down: decrease

Fl/Flex flexion

Ext extension

Abd abduction

Add adduction

IR internal rotation

ER external rotation

HF horizonal flexion
HE horizonal extension

Inv inversion

Ev/Eve eversion

DF dorsiflexion

PF plantarflexion

El/Ele elevation

Dep depression

Protr protraction

Retr retraction

Med medial

Lat lateral

Rot rotation

PPIVM Passive physiological intervertebral movements

PAIVM Passive accessory intervertebral movements

ULNT upper limb neurological tests

LLNT lower limb neurological tests

Px pain

^O Px no pain

P1 pain 1

P2 pain 2

ROM range of motion

FROM full range of motion

VAS / 10 pain score

NRS pain score

3/12 months

2/7 days

4/56 weeks

THREADS
Thyroid, heart, rheumatoid arthritis, epilepsy, asthma, diabetes, steroids

R right

L left

NSAIDs non-steroidal anti-inflammatories

# fracture

^O# no fracture

+ive positive

-ive negative

R = L symmetrical

R < L right less than left

R > L right greater than left

AROM active range of motion

PROM passive range of motion

FH family history

PMH previous medial history

RF rectus femoris

Cx cervical spine

Tx thoracic spine

Lx lumbar spine

Pt patient

Ax assessment

Rx treatment

Dx diagnosis

DDx differential diagnosis

ADL active daily living

FWB full weight baring
PWB partial weight baring
NWB non weight baring

S/Sx sacral spine
ACJ acromioclavicular joint

QL quadratus lumborum

Gmax gluteus max

Gmed gluteus min

LBP lower back pain

CLBP chronic lower back pain

MET muscle energy techniques

STM soft tissue massage

STR soft tissue release

DTM deep tissue massage

Other discussions within this day involved particular subjects that crossed over with academic literature and was incredibly thought provoking, such as how we feel pain and whether this truly is a measure of injury; is pain really indicative of injury or a learnt sensation? I realised that there was a great need for the cross over between research and literature and with physical treatment sessions and practice; the evidence is changing so rapidly and it is for us as therapists to stay on top of the new research and to really engage in emerging treatments.
We were also treated to a talk by a doctorate student who was undergoing her own research project on disc herniation and traction, which at the time of the talk was all very new to me. As the months passed, I watched her ongoing work during sessions, asked questions and engaged in discussions with her, and have found that I too have become inspired to embark in my own form of further research one day when I stumble across an area that truly inspires me too.
It is also during this session that I first came across the true value of musculoskeletal therapists for the everyday living of the non-athletic populations, particularly the difference that very simple exercise can make on the alarming statistics on falls among the elderly. Who would have known that I would become far more inspired by these treatments than in athletes and that working to help restore and maintain good physical function in those slightly more impaired (such as the older population or inactive individuals trying to take up new sports) would interest me the most. I know from experience and evidenced based literature that exercise truly is the best medicine and preventative and I will make it my life long work to also inspire people to get as active as they can within their means and ability but to also push their ability if physical function is their own impairment. I want to seek the knowledge and experience to be able to embark in a profession that guides those who may have physical or psychological barriers to exercise to help offload these and facilitate their return to sport or their first ventures into a more active lifestyle.

Throughout the entire day, the clinic managers made themselves available for general discussion and to provide clarity on many aspects of clinic life and outlined their expectations of us as therapists and of also sought feedback on what we were expecting from them and the clinic. I found this time incredibly important, as it allowed us to start building a rapport with each other and with the managers so that we felt comfortable enough in their presence to be able to ask questions and seek help if needed; something I feel has been one of the most effective reasons why I have learnt so much from clinic this year. By creating an encouraging, positive means of communication between us all and from the managers portraying such an inspiring enthusiasm for what they do, I came away from the introduction day positive and excited to learn and not worried and anxious as I had anticipated. It is for this very reason that I jumped into my clinical experience with full gumption and felt ready to learn and for that I am very grateful to them both; thank you Alex and Mike, I owe much of my development as a therapist to you.

Closing reflections from my clinical experience module at Marjon University

My confidence throughout my time in Exeter college did not develop as much as I would have liked in order to feel ready to embark in a career as a self-employed sports therapist. Although I overcame this and tentatively developed a small client base, I only offered sports massage at very low cost. This was largely due to the fact that I did not feel as though I had gained enough experience to understand the true extent of the assessment process most likely due to my low confidence affecting my eagerness and drive to get stuck in and learn.
One of my biggest motivations for embarking in this journey at Marjon University was to gain the confidence and knowledge that I needed in order to grow as a therapist, enough to expand my services to offer sports injury diagnosis and treatment; the full capacity of a sports therapist. I wanted to be able to add more focus and meaning to my treatment and have the understanding of anatomy and physiology and injury mechanisms to be able to further help patients to not only treat the symptoms of their ailments, but to identify and subsequently treat the cause. I found that many of my patients who initially came to me for a sports massage had many other questions that I simply couldn’t answer. I knew that for many of these patients, sports massage was not enough and that I could have been doing more for their treatment and performance as athletes or wellbeing and quality of life for members of the general population. It was my desire to go above and beyond for my patients that brought me to this course.
In my opinion, the reason why I feel as though I have gained far more experience from my time at Marjon was my enthusiasm to get involved and to soak up as much of the experience as I possibly can. Instead of shying away and doing as much as I could to get by, I threw myself into clinic, knowing that this would be a far better way to learn. I asked all the possible questions, I researched before and after clinic to expand my knowledge on each and every patient as I possibly could and I threw myself into situations that challenged me or that made me feel overwhelmed. I learnt to accept my short comings so that I was able to pay more attention and put more effort in to improving these areas.
I feel as though the two years gap between my second and third year did affect my anatomy knowledge somewhat and my diagnostic skills (as I did not need these for massage alone), however it did allow me to really identify the areas of knowledge that I was lacking.
I knew I had much to learn, but more importantly, I felt as if I knew what it was that I had to learn. I knew what I did not know and I knew how I was going to gain this knowledge.
Ironically, I also feel as though these very reflections were the key to my confidence this year. By having this as an assignment to be completed throughout the academic year has given me a focused and incredibly valuable outlet for my own experiences and provided me with scope to further my learning. I am very grateful for this resource as I feel as though I now not only have a reference guide of my own experiences to refer back to in the future, but I have a much better understanding of the cases that I have treated and in my ability to treat.

What is next for me as a sports therapist?
From the nature of the clients that I have seen throughout my time at both the Marjon Health and Sports Injury Clinic and Exmoor Osteopaths, I have gained further interest in treating the general public with the main aim of improving quality of life and wellbeing as opposed to the traditionally thought role of treating athletes with injuries or helping them to perform better and achieve more. I have gained a tremendous amount of satisfaction from helping these patients to live their lives with less or no pain and more function and to help educate them on how to understand and self-manage their ailments.

From the effort and enthusiasm of my time spent at Exmoor Osteopathy and Sports Injury Clinic, my external placement provider, I am now in a fortunate position to have been asked to return to them when my degree program ends in order to discuss further arrangements, most likely regarding room/equipment hire and unofficial joining of businesses. It is my understanding that they are looking to expand their business premises from just two rooms to four and as they are a business of two osteopaths, that leaves room for another practitioner. I have since found it very difficult to find premises that I can work from that is safe and inexpensive; I do not feel happy visiting clients’ homes, as I feel that this compromises my safety and therefore have been seeking a suitable alterative. It is my hope that I would be able to work within their clinic and help to provide them with a means to offload waiting lists or refer clients who need more rehabilitation and exercise based programs (I feel as though this in an area that I am more experienced and willing; osteopathy treatment in this clinic is much more symptom focused and does not include much rehabilitation at all). I would be thrilled to help facilitate business expansion with them, as well as work alongside two incredibly well reputable osteopaths while building my own client base who trust my integrity and whom value my professionalism and knowledge as I do them.

I owe a tremendous amount of gratitude to those who have given me so much of their time and shown me so much patience when learning these clinical skills, particularly Mike, Alex and Kat; their enthusiasm and passion for what they do has fed my own passion and love for sports therapy and I’ll always be grateful to them.

Total Hours: 196
External Hours: 50
Clinic Hours: 146

Patient 1 – STM and Quality of life Questionnaire
I was due to see my regular patient today, however this patient cancelled at the last minute leaving me with only one patient today which is a great shame, as I feel as though I have missed out on many learning opportunities over the past few months and also the ability to record valuable clinic hours to add to my log. I also did not get to hand out a quality of life questionnaire which I was excited to trial, however I believe the patient has rearranged again for a week’s time; I will be well prepared.

Patient 2 – Pain and swelling in knee from trauma 6 months ago; awaiting knee surgery through NHS.
This patient was an elderly lady who arrived to the clinic with her husband. When greeting her, I took the opportunity to start my observations as she got out from her seat and made her way to the cubicle; she needed walking aids and her husband for extra support. I was quite shocked by the amount of swelling in her knee and the obvious discomfort that she was in and I feel like it affected me, however I was sure to remain professional when discussing her action plan.
In my time at the clinic, I hadn’t come across a patient who has been affected so much in her family life, not only by reduced functional ability but by significant pain. When going through the subjective assessment, my patient got very emotional which to me, was a major indicator as to how much this was affecting her; I reassured her that I would do what I could to ensure that she had a good plan of action to take away with her.
After a short discussion with the manager, it dawned on me how important follow up appointments are and that the patient can just as easily cancel if they don’t feel the need to attend. By offering this patient a follow up, I am offering our services as a long-term care plan, as opposed to leaving the treatment without end; the patient may feel as though we have done all that we can and that there is little we as a clinic can add. Although I did suggest returning for further advice or treatment, but actually booking something adds continuity of service and peace of mind for an appointment in the near future, unlike the NHS and their challenging appointment process at times.

With regards to the exercise prescription, both the clinic manager and I agreed that a program of simple exercises to strengthen to knee would help to relieve pain and better support the join to reduce symptoms but it was our belief that this would better improve the outcome of knee replacement surgery as shown in a review by Wallis & Taylor (2011).
However, according to Gill & McBurney (2013) in a and meta-analysis of RTCs regarding knee and hip surgery and the prescription of exercise pre surgery, although hip outcome measures improved from a pre-surgery exercise program, pre knee surgery patients experienced no significant difference in outcome scores. I was surprised by this; however I would still advocate the use of strengthening as it did not seem to have any negative affect on the patients but in my opinion only provides hope and focus for those awaiting surgery. Reviews may not always include all research available and they are not without their limitations, for example Gill and McBurney (2013) and did not include psychological elements to their outcome measures and included 18 RTCs whereas Wallis & Taylor (2011) included 23.

When demonstrating and going through the sit-to-stand, I felt pleased knowing that I had come up with the initiative to get a non-wheelie chair. Often, with elderly patients they struggle to use the movable chairs and I was very aware that this would have proved difficult for this patient. I did not use a lowered treatment bench either, as this did not have handles. In the absence of a chair in future, I could have offered my hands as support, but know that something this may feel uncomfortable for the patient. I also wanted to create a scenario of exercise which the patient could take home with them and do by herself.

I was quick to request assistance from the clinic manager, as I was initially taken aback by the inflammation and obvious pain and dysfunction, however over the course of the session I realised that I was probably far more capable than I realised at the time. Unfortunately, there isn’t much immediate pain relief that I could have offered the patient at the clinic, as much as I would have loved to do. I did make sure that I offered her plenty of reassurance as to the outcome of the session, her cooperation to strengthening and the prospects of surgery in the near future. I feel that the patient felt happier leaving the clinic than arriving and I hope that by calling her for a follow up to find out progress and offer further treatment, I may be able to see for myself the differences that strengthening has made on her pain, function and perception of pain.

References –

Gill, S. D., & McBurney, H. (2013). Does exercise reduce pain and improve physical function before hip or knee replacement surgery? A systematic review and meta-analysis of randomized controlled trials. Archives of Physical Medicine and Rehabilitation. https://doi.org/10.1016/j.apmr.2012.08.211

Wallis, J. A., & Taylor, N. F. (2011). Pre-operative interventions (non-surgical and non-pharmacological) for patients with hip or knee osteoarthritis awaiting joint replacement surgery – a systematic review and meta-analysis. Osteoarthritis and Cartilage. https://doi.org/10.1016/j.joca.2011.09.001

Total Hours: 195
External Hours: 50
Clinic Hours: 145

Patient 1 – STM of legs; hamstrings, quadriceps and gastrocnemius muscles.
From my previous week of treatments, it was reinforced that communicating to the patient about their daily activities may reveal more about their injury or risk of injury than a subjective assessment itself, as often they talk about things that don’t seem relevant to them at the time of questions and/or they feel more comfortable talking about themselves later in the treatment session.
Although this patient was clear in request for a STM, through conversation, I revealed the need for education on training load as preventative measure.
As I have found in recent treatments, patients have responded well to visual cues through photos and diagrams such as with various different exercise routines. As I found the concept of tendinopathies challenging to grasp, I anticipate it may be difficult for patients to fully understand too, therefore by showing them the table that best taught me, I would be able to give the opportunity to better understand the importance of managing load to reduce the chance of injury (Cook & Purdam, 2009; Lewis, 2009).
An example of a continuum is shown below and although this was derived for the rotator cuff it is still a useful guide to the pathology.

In the past, questions about workload and training schedules did not occur to me until much later in the treatment, however I have come to realise the importance of this and the importance of clear communication with the patient regarding appropriate loading. The patient had informed me that he started to increase his load from January after entering an ironman in July this year, however he also explained that he had never done anything like this before. I did take into account that this patient was in the military and so had a very good basic level of fitness, however this does not mean that he had an appropriately loaded tendon for the increase in running and I explained that even if there are currently no symptoms, that pain isn’t necessarily a good indicated of a tendon pathology as this is accumulative in nature and may not present itself as pain until after the tendon is in the reactive tendinopathy or disrepair phases. I did not want to make my patient apprehensive about training, but I felt that it was very important to make him aware of overload. He did report low level discomfort in his achillies tendon, which I advised he used as an objective measure over the coming training months; reduce load and if the pain is less up to three days after training, then this is a good indication that the load was appropriate. If the patient experiences increase in discomfort, then he knows to reduce his load.

With regards to the massage treatment, I am always vigilant when it comes to ensuring that I am applying the appropriate pressure. Some patients are much more reluctant to say that they would like more or less pressure so I am careful to always ask for feedback throughout and try to maintain a relaxed atmosphere so that they would feel comfortable in saying.
This patient did ask for more pressure at times, but equally felt that at some points, I was applying too much. Although this may seem inconsistent, I was reassured by the fact that I was providing a large area of massage that included some more sensitive areas than others. However, it may be an indication that I need to try to be more aware of which muscles I am targeting and the pressures that they may be able to withstand, for example this patient was a cyclist, a sport in which cause notoriously “tight” quadriceps, so with this in mind, I could have been especially sensitive in this area.

Patient 2 – Once again my patient did not arrive and although this is extremely frustrating for myself as I lose out on the opportunity to gain valuable experience, however I still got to take advantage of the equipment and the knowledge and experience of other students and we took the chance to practice spinal anatomy. Even though this was a first year learning task, it still remains a challenge for me to efficiently palpate and identify the correct spinous processes, especially when the patients have a higher percentage of body fat. When working with live patients, I often spend too much time trying the exact location of any pain or treatment area and sometimes I am not sure. This is not so much of an issue when treatment is concerned as I can treat the symptoms based on patient feedback and my objective assessment, however when writing notes for other therapists to see at follow up appointments, it is important to write in as much accuracy, the location and type of treatment.
For example, if a patient has stiffness in T4 through to T6 and I performed central PA mobilisations in treatment, but did not state the location, in future appointments, therapists may not know the benefit or ineffectiveness of the treatment if they have no information as to previous sessions. Also, if the location of when I performed treatment is inaccurate, then in future assessments, objective information may not present in an expected way.
I do understand the importance of practice and the need for experience in palpating many different spines and those with or without dysfunction/pathology, however I do not always get the chance to do so.
By practicing on another student, I was able to ask for feedback as to how it feels for them for me to prod them and also ask other students to help identify landmarks with me, a luxury that I do not have when working with patients and when I finish this course.

I learned from this practice that counting from C1 through to the distal spine is not the most effective means, but that making relative location associations at varying levels was.
In order to learn a good method of remembering spinous process locations, we brought up a video to guide us, which can be seen in the following link:

Cervical Spine: https://www.youtube.com/watch?v=6azgWYMQfWU&t=135s

C6 disappears when patient extends neck, C7 remains prominent!

Thoracic Spine: https://www.youtube.com/watch?v=3hRFXCgnABE

T7 inline with inferior angle of the scapular

Lumbar Spine: https://www.bing.com/videos/search?q=palpating+spine&&view=detail&mid=D0925B3114E7265DD374D0925B3114E7265DD374&&FORM=VRDGAR&ru=%2Fvideos%2Fsearch%3Fq%3Dpalpating%2520spine%26qs%3Dn%26form%3DQBVR%26sp%3D-1%26pq%3Dpalpating%2520spine%26sc%3D4-15%26sk%3D%26cvid%3D7BCF41200DB24C4394E2DB3D08B4A1DE

Iliac crest = L4/5

Patient 3 – Follow up treatment for shoulder and thoracic pain and restriction
This patient has been returning to the clinic for over 4 months for treatment of the shoulder and thoracic spine. Over this time, his mobility and pain has improved to a point that he is almost free of any symptoms. Each time he returns he reports slight discomfort shortly after treatment which eases within a few days but I always explain that this is to be expected.
This patient usually commits well to his exercises, however on this occasion he had done very little over the previous four weeks. Interestingly, there was no worsening of symptoms from this, therefore we felt confident that over the course of sessions, this patient has developed a good level of stretch and that we have managed the level of rehabilitation appropriately. I was careful to advise the patient to gradually get back into his exercises, as opposed to jumping straight back into it, so as to avoid any overloading of potentially deloaded tendons of his shoulder.
At the point in his rehabilitation, the patient seems to be returning regularly but only for passive sport massage of which he feels benefits him and facilitates his strengthening program.
I am much better at managing my time during sports massage now and ensure that organise my time in chunks of area to massage, so that I do not run out of time and this session seems to go as planned.
Due to an increase in pain over his T3-T4 spinous processes (now that I feel more confident in palpating and identifying them after practicing earlier in the session), I did not perform PA mobilisations as per usual treatment, so as not to irritate any muscle attachments over the site of mobilisations.
I reviewed all of his exercises and went through each one again just to ensure that he is happy with how to perform them, as he hasn’t done them for over a month. I have found from experience that physically demonstrating and practicing the exercises with the patients better ensures their compliance in their home program, as I can make sure that they know what is being asked of them and also the reasons why. Just writing down exercises on a sheet usually is not the most effect, as many patients report losing or misinterpreting the information.

References – 

Cook, J. L., & Purdam, C. R. (2009). Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British Journal of Sports Medicine. https://doi.org/10.1136/bjsm.2008.051193

Lewis, J. S. (2009). Rotator cuff tendinopathy/subacromial impingement syndrome: Is it time for a new method of assessment? British Journal of Sports Medicine, 43(4), 259–264. https://doi.org/10.1136/bjsm.2008.052183

Total Hours: 192
External Hours: 50

Patient 1 – Pain in neck and shoulders
My first patient of the evening did not arrive, so I partnered up with a fellow student who was conducting an assessment on the cervical spine and shoulders.
It became apparent early on that this patient was going through a very difficult time at home and as such much of the initial subjective assessment was spend discussing this and listening, which I have come to learn is an incredibly important aspect of our role as therapists. From this, a pattern of pain emerged and the patient herself understood the implications of the stress on her musculoskeletal health. I find it difficult to explain to patients that there may be a psychosocial element to their discomfort, as I do not want them to think that I am suggesting their pain is in their head, however fortunately, this particular patient works in mental health and is intelligent in this area. Nonetheless, we were very sensitive to her struggles and together we provided a calm, relaxed but professional environment and tried to derive a self-management plan for her pain in case she was unable to return to the clinic in the near future.
This patient often worked on computers at work which is commonly associated with forward shoulder posture (Szeto, Straker, & O’Sullivan, 2005), which was evident, although this was not objectively measured only seen through observation and self-reported by the patient.
Because there were two therapists treating this patient, we were able to really engage in conversation with her and listen.
Our objective measure was the endurance test, whereby the patient lies supine and lifts her head off of the couch with chin tucked in for as long as possible; the patient could only last 4 seconds, where expected would be more in the range of 40 seconds!
This indicated to us that the patient should look to strengthen her deep neck flexor muscles and be more consciously aware of her posture. Exercises to increase muscle strength in the thoracic/scapular muscles, combined with stretching of the pectoralis minor muscles have been found to reduce forward shoulder posture and associated pain (Hajihosseini, Norasteh, Shamsi, & Daneshmandi, 2014; Harman, Hubley-Kozey, & Butler, 2005; Kotteeswaran, Rekha, & Anandh, 2012). We prescribed Y exercises using an exercise ball, scapular squeezes, low rows and door frame stretching, all exercises that this patient can do at home and that I have readily prescribed in the past.

When administering soft tissue massage, my fellow student therapist and I both treated a shoulder each, which initially we felt would be more efficient, however we soon realised that because we were so different in our technique, the patient was comparing the pressure and may have felt uneven. Just because I applied more pressure does not necessarily mean it was more effective, so in future I would look to perform treatment on an entirely different area such as the thoracic spine, so that the patient could not compare.

This patient left the clinic in high spirits and felt positive about her treatment and her take home plan. I made sure to ask for feedback throughout to make sure that the patient was happy with her plan to increase the chances of adherence.

Patient 2 – Soft Tissue Massage of TFL and Lateral Hip Abductors
This patient requested soft tissue massage of her “IT Band” only.
Initially, I felt as though this patient was quite reserved and anxious about her treatment due to her quiet and non-conversive manner at the start of the treatment. This was reinforced by her request to treat only one area. In order to better understand any worries my patient might have had, I was sure to ask whether he had had any previous soft tissue massage, to which she replied that she had. This reassured me that she was aware of the procedure and that her anxieties, if any, did not stem from inexperience; sometimes patients can be worried when they do not know what to expect. Nonetheless, I continued to treat this patient sensitively, respecting her choice of minimal communication.
Throughout the treatment, I gave the patient time and space to communicate at her pace if desired but did ask the odd very open question. Quite often I engage in interesting conversations with the patients, which can be flowing, animated and enjoyable however, by appreciating the need of calm and quiet with this particular patient, she eventually did begin to feel more comfortable and open up and by the end of the session. I felt as though I had the opportunity to discuss her running and the reasons why she may be experiencing tightness in her glutes and/or TFL. Communication is an extremely important aspect of sports therapy and if I am able to build a rapport with my patients, any advice that I may offer them may be taken away with a little more confidence and motivation. Although this patient did not present with an injury as such, there was slight discomfort and tension when running.
I advised the patient that although there are benefits to STM and that that treatment would help to relieve tension and manage symptoms (Falvey et al., 2010), this was not the only way to manage a potentially ongoing discomfort and as such we discussed ways for her to self-manage the onset of further discomfort.
As this patient has an intensive running schedule and has been running for years she had established a well thought out training plan that seemed to limit excessive loading or change in load and she understood the implications of not doing so. She was currently spending 10minutes per day performing exercises that she had found herself and reports excellent compliance and effects from this. In my opinion, this patient was self-managing her discomfort excellently and my only advice to this patient was to incorporate an element of stretching into her daily routine, as she had not previously done so. This was because she was unable to find a stretch that targeted the right area. When demonstrating a stretch for this patient, I realised that I wasn’t entirely sure of the most effective method and couldn’t fully work out the correct routine. I had to research this online, as well as ask the clinic supervisor.
We spent quite a long time trying to work out the most effective stretch, based of how the patient felt but to no avail. It became apparent that the patient was experiencing most discomfort more specifically in her glutes and that a gluteal stretch was more appropriate. From my anatomy knowledge I know that the gluteus maximus inserts into the tensor Fascia Latae and I should therefore have tried a number of these stretches first. I have since practiced a range of stretches and have a bit more experience with how to demonstrate these. The stretches in the following video were found to be most effective for this patient;
https://www.youtube.com/watch?v=MO2ZNz03YEI

In order to fully appreciate the efficacy of advising stretches for these, I conducted some research around iliotibial band injuries and associated pain.
ITB syndrome is prevalent among runners and can be seen in between 5 and 15% (van der Worp, van der Horst, de Wijer, Backx, & Nijhuis-van der Sanden, 2012) and is a repetitive use injury that derives from the continuous flexing and extending of the knee.
When treating this patient, I did not take into consideration a differential diagnosis, or at least encourage the patient to consider the potential of other structural involvements, for example bursitis of the bursae on the lateral femoral condyle, as this makes contact with the TFL and could present with symptoms similar to the pain in the ITB or associated structures which the patient assumed was tightness or tension (Falvey et al., 2010). The term ITB syndrome is broad and covers an array of dysfunctions, however the treatment may remain similar to some extent. Any direct pressure on the inflammation should be avoided, such as deep friction massage, especially over the area of bursitis if present, however massage and stretching of the associated structures is advised as well as exercises to target weaknesses in the lateral hip abductors, which this patient had already been doing (Brown, Zifchock, Lenhoff, Song, & Hillstrom, 2019; Falvey et al., 2010; van der Worp et al., 2012).

Research conducted by Brown et al. (2012) challenged the well documented associations between weakness and IT Band syndrome, however they further investigate the effects of duration exercise on fatigue and instead of identifying weaknesses in the gluteal muscles, of which there was no significance, the gluteus Medius muscles were less able to resist fatigue.
From previous research I have learnt that in order to invoke a fatiguing response on muscles to develop their ability to withstand duration of loading, strengthening needs to include higher sets but of lower loads (Reiman & Lorenz, 2011). These are especially useful in postural muscles that have to withstand low levels of load continuously to stabilise the body in rest and activity. So although testing for this patient revealed 5/5 strength that does not mean that he abductors have the optimum ability to withstand fatigue and as such strengthening in conditions of fatigue may be a good focus; I made sure to increase reps of exercises for her home strengthening program.

As I advised my patient, that although the use of STM and foam rolling is a good way to relieve symptoms (Wiewelhove et al., 2019), it is not an effective means of long-term treatment as it does not address the case. Research by Falvey et al. (2010) found that intervention targeted at any shortening of the muscular components of the iliotibial tract, such as the gluteus maximus and tensor fascia latae muscles may be more effective that the IT Band itself which shows little mechanical lengthening at all. This same review found that although there is some evidence to support the use of deep tissue massage, it is no more effective combined with stretching than stretching alone and therefore I feel confident in prescribing a stretching routine for the patient to facilitate their home strengthening routine (van der Worp et al., 2012). I instructed the patient, therefore to continue to strengthen the lateral hip abductors and glutes and to manage symptoms such as tension and tightness using a foam roller and stretching, but of the TFL and glutes as opposed to the IT Band, so as not to irritate any inflammation that may be present.

Throughout my time in clinic, I have tried to remember to test patients before and after treatment or programs using objective markers so that I can measure the effectiveness of treatment and fortunately I knew how best to do so on this occasion. The OBERS test and the modified Thomas test have both been recommended as a means to objectively measure treatment or to pre-screen athletes who may be pre disposed to injury (van der Worp et al., 2012). Although there were no bilateral differences in this patient, the dysfunction experienced in her left side was enough of an indication. This is a useful measure for the patient to take home with her, as she can retest this to measure any changes in pain, in case she does not return to the clinic. I advised her to regularly assess her own levels of discomfort and adjust exercise plan accordingly.

References –

Brown, A. M., Zifchock, R. A., Lenhoff, M., Song, J., & Hillstrom, H. J. (2019). Hip muscle response to a fatiguing run in females with iliotibial band syndrome. Human Movement Science. https://doi.org/10.1016/j.humov.2019.02.002

Falvey, E. C., Clark, R. A., Franklyn-Miller, A., Bryant, A. L., Briggs, C., & McCrory, P. R. (2010). Iliotibial band syndrome: An examination of the evidence behind a number of treatment options. Scandinavian Journal of Medicine and Science in Sports. https://doi.org/10.1111/j.1600-0838.2009.00968.x

Hajihosseini, E., Norasteh, A., Shamsi, A., & Daneshmandi, H. (2014). The Effects of Strengthening, Stretching and Comprehensive Exercises on Forward Shoulder Posture Correction. Physical Treatments – Specific Physical Therapy Journal, 4(3), 123–132. Retrieved from http://ptj.uswr.ac.ir/article-1-170-en.html

Harman, K., Hubley-Kozey, C. L., & Butler, H. (2005). Effectiveness of an exercise program to improve forward head posture in normal adults: A randomized, controlled 10-week trial. Journal of Manual and Manipulative Therapy. https://doi.org/10.1179/106698105790824888

Kotteeswaran, K., Rekha, K., & Anandh, V. (2012). Effect of stretching and strengthening shoulder muscles in protracted shoulder in healthy individuals. International Journal of Computer Application, 2(2), 111–118.

Reiman, M. P., & Lorenz, D. S. (2011). Integration of strength and conditioning principles into a rehabilitation program. International Journal of Sports Physical Therapy.

Szeto, G. P. Y., Straker, L. M., & O’Sullivan, P. B. (2005). A comparison of symptomatic and asymptomatic office workers performing monotonous keyboard work – 2: Neck and shoulder kinematics. Manual Therapy. https://doi.org/10.1016/j.math.2005.01.005

van der Worp, M. P., van der Horst, N., de Wijer, A., Backx, F. J. G., & Nijhuis-van der Sanden, M. W. G. (2012). Iliotibial Band Syndrome in Runners. Sports Medicine. https://doi.org/10.2165/11635400-000000000-00000

Wiewelhove, T., Döweling, A., Schneider, C., Hottenrott, L., Meyer, T., Kellmann, M., … Ferrauti, A. (2019). A meta-analysis of the effects of foam rolling on performance and recovery. Frontiers in Physiology. https://doi.org/10.3389/fphys.2019.00376

Total Hours: 190
External Hours: 50
Clinic Hours: 140

Patient 1 – Pain on dorsal/medial surface on foot when running; possible overuse
The following is a summary of the relevant information from assessment:
S: patient has reduced running load since Christmas from 40km per week to 16km approx. which initially I couldn’t see a problem with, however even though the frequency of running has reduced and overall mileage, the patient explained that he was still running long runs, but at a higher speed and with longer rest in between.
Although reducing load is not normally indicative of overusing or overloading a tendon,
other factors such as general health may also have played a role in the development of a tendon pathology as the body’s ability to regenerate collagen and repair itself is compromised in conditions that affect inflammatory responses (Curtis, 2016), such as those associated with the thyroid. Although there is no direct evidence on the effects on hypothyroidism and tendon pathology (Oliva, Berardi, Misiti, & Maffulli, 2013), the thyroid has been found to affect the development and maintenance of metabolic systems has been found to increase collagen type I as well as cartilage oligomeric matric protein, both of which are associated with tendon alignment (Berardi et al., 2014).
This patient does take medication for hypothyroidism names as thyroxine and as such we discussed his susceptibility and/or increased risk of tendon pathologies and the need for a careful training program. Thyroxine reportedly facilitates synthesis of collagen and is given to patients with hypothyroidism to help reduce the effects of this hormone on tendon health; those with the condition and reduced thyroid gland function have been found to have an increased risk of calcification in the tendon.
It is advised that by medication, managing the thyroid disorder would be the most effective treatment in tendinopathies, however this patient was already in control of his condition. This lays the focus of treatment on a program of exercise whereby the patient develops a more consistent running plan; increases frequency but reduces speed and distance. By doing so, the tendon is not overloaded sporadically throughout the week, but given a more gradual and progressive load.
To facilitate this, I also found exercises to strengthen his foot as a whole complex to be effective in previous treatments of non-specific tendon type pain not only as a way of better supporting the ankle and foot muscles as a whole, but by prescribing a plan for the patient that brings a new dimension to his training, to add focus and additional motivation for continued progress. Exercises such as those found to be effective in the strengthening of the arch muscles, such as the tibialis posterior, the peroneals as well as flexors and extensors were all given to the patient with reps to stimulate fatiguing responses and therefore more realistic of the functional and continuous motions of running (Lee & Choi, 2016).

I also educated the patient on cadence and to consider increasing this to reduce ground reaction forces each time her plants his foot (Hafer, Brown, deMille, Hillstrom, & Garber, 2015). I felt confident that my knowledge on pre disposing risk factors of tendon injuries gives me plenty of information to share with my patients to make sure that they are well informed of how to reduce their risk of injury or manage their training loads. By sharing this information, I am able to empower the patient to take better care of themselves by the simple fact that they understand the factors involved with the development of injury.

Patient 2 – Group discussion on case experiences while carrying out clinic duties
My second patient who was due to attend the clinic could not make the session but without prior notice, as is unfortunately a common occurrence. I was not alone in my lack of patients and so I sought discussion from other students. While we folded towels and carried out other clinic duties, such as refilling lotions, cleaning and writing notes, we engaged in a discuss on how we demonstrated our exercises to patients and by what means do we provide the information. At present, I write down the exercises onto a rehabilitation sheet, as per the protocol of the clinic but I also ensure that I demonstrate each exercise and ensure that the patient can perform them too. Quite often, I have explained an activity to a patient who has expressed their understanding, only for them to be unable to perform it when asked! And as mentioned before, with patients who I have prescribed a plan to but did not spend time demonstrating and practicing the exercises, they have self-reported lower adherence rates.
Other students used similar methods and found the same issue with some patients. It is most likely not uncommon to see a variety of patients whereby some need more motivating that others, so having a wide range of resources could prove useful in the future. Generic go-to hands out may be quite useful for me to create and have readily available to pass on to patients for specific conditions that I may find quite common in the clinic or for the population group that I will be working with most. Conditions such as non-specific lower back pain, tendon injuries and general muscle weaknesses could all have their own hand out which demonstrates pictures and visual guides to what is expected, as well as a blank space for sets and reps to be added in order to personalise the program.

It was suggested by one of the students that a website by Ex Rx (https://exrx.net/) had proved invaluable in their learning of exercises and was an excellent resource to use, either to learn from or to direct patients to.
I will take it upon myself to spend my final weeks at Marjon taking and collating a variety of photographs while using the rehab area (as this will provide a good professional environment) to derive such information hand out sheets. I understand that this will take time as I develop my understanding of exercise prescription and associations with certain injuries, however if I gradually take photos and collect information from websites such as this, I can slowly create a small catalogue of information to pass on to clients which could also include adherence tables, all of which will help to increase compliance and adherence to rehabilitation programs, an important factor in the successful outcome of programs (Picha & Howell, 2018).

I would not have known about the website with these fantastic resources on them, had I not have spent time asking other students of their sources and what their clinical intentions may be when they finish this course. I am excited to derive my own information sheets but also look at the potential benefits to creating a website with this information too.

References – 

Berardi, A. C., Oliva, F., Berardocco, M., la Rovere, M., Accorsi, P., & Maffulli, N. (2014). Thyroid hormones increase collagen I and cartilage oligomeric matrix protein (COMP) expression in vitro human tenocytes. Muscles, Ligaments and Tendons Journal. https://doi.org/10.11138/mltj/2014.4.3.285

Curtis, L. (2016). Nutritional research may be useful in treating tendon injuries. Nutrition. https://doi.org/10.1016/j.nut.2015.12.039

Hafer, J. F., Brown, A. M., deMille, P., Hillstrom, H. J., & Garber, C. E. (2015). The effect of a cadence retraining protocol on running biomechanics and efficiency: a pilot study. Journal of Sports Sciences. https://doi.org/10.1080/02640414.2014.962573

Lee, D., & Choi, J. (2016). The Effects of Foot Intrinsic Muscle and Tibialis Posterior Strengthening Exercise on Plantar Pressure and Dynamic Balance in Adults Flexible Pes Planus. Physical Therapy Korea, 23(4), 27–37. https://doi.org/10.12674/ptk.2016.23.4.027

Oliva, F., Berardi, A. C., Misiti, S., & Maffulli, N. (2013). Thyroid hormones and tendon: Current views and future perspectives. Muscles, Ligaments and Tendons Journal. https://doi.org/10.11138/mltj/2013.3.3.201

Picha, K. J., & Howell, D. M. (2018). A model to increase rehabilitation adherence to home exercise programmes in patients with varying levels of self-efficacy. Musculoskeletal Care. https://doi.org/10.1002/msc.1194

Total Hours: 188
External Hours: 50
Clinic Hours: 138

Patient 1: Follow up STM for neck and shoulder stiffness
Research spinal stenosis of lumbar and likelihood of occurring in cervical spine
Quality of life questionnaires

This patient was my regular elderly woman who requests STM of her neck and shoulders and presents with almost completely restricted ROM in bilateral side flexion, extension and bilateral rotation of her neck as well as limited ROM in abduction, internal rotation and flexion in her left shoulder. This patient has seen slight increases in motion over the course of the academic year in which she has sought treatment, however changes have often been minimal on a session by session basis, leaving me feeling unsatisfied with progress. Because the patient feels too uncomfortable lying on the couch and requests only STM while seated, I have had limited options in treatment. I have spent much time going through exercises to increase shoulder and neck ROM, reduce rounded shoulders and improve posture, however I continue to question whether these treatments were helping to make a difference to her throughout her daily life; daily living tasks such as getting her coat on and gardening still remains a challenge to her.
Each session, as ROM has been difficult to measure, with changes minimal I was at a loss as to have to measure progress or treatment effectiveness to offer the patient with hope and positive feedback where possible.
This patient was currently reporting pain as her measure, however over the course of the treatments it seems that both pain and ROM will likely remain an issue and as such continuing to focus on these limitations may not prove beneficial to her wellbeing, emotional and physical as it is reported that chronic pain can effect sleep, cause depression, reduced mobility and fatigue (Hawker, 2017). With this in mind, I sought to find another means of measuring this patient’s progress that did not involve negative pain or limitations in ROM.
As might be the case with this patient, using pain questionnaires such the reliable VAS pain questionnaires (Hawker, Mian, Kendzerska, & French, 2011) may just highlight the fact that there is some degree of constant chronic pain but without putting it into context. It was suggested by the clinic manager that quality of life questionnaires may be a useful tool in measuring session by session changes by other psychosocial means, such as improvements in sleep and or general daily living tasks as well as more subjective physical functional ability in relation to their perception of pain (Beaudart et al., 2018; Picavet & Hoeymans, 2004).

The following is an example of the quality of life questionnaire (MSK-HQ) derived by Oxford University to be published by ‘versus arthritis’ https://www.versusarthritis.org/media/7833/msk-hq-2018.pdf. This is appropriately pitched for my patient as it covers basic living tasks, it is simple to fill in and won’t take up too much time. I will hand to my patient to fill out in their own time, which could provide a more dynamic measure of how treatment has worked/is working without focusing solely on pain, which may always be present, but on how it affects her functional ability.

Patient 2: possible strain of wrist flexor/pronators from trauma, reduced Lt Tx mobility and associated tension in upper traps and rhomboids
Cyclist presenting with shoulder flexion pain and limited ROM after fall.
Initially I started to assess the shoulder but it soon became apparent from flexion movements both resisted and active that the biceps, is initially thought due to the insertion beyond the elbow, was not the primary issue. This highlighted the importance of assessing the joint above and below, as sometimes the presentation of pain isn’t indicative of the source. And although the patient came in for shoulder, as a therapist I should remain more open minded as to the location of the dysfunction or pain.

The following is a brief summary of subject and objective assessment notes:
Cx: Full active and passive ROM
GH Jt: discomfort at end range of Abd., Ext. and Int. Rotation of Lt shoulder but no Px in any movements. All other full active, passive and resist. ROM. Slight Px in full resisted flex end range.

Tx: restricted in Lt rotation, compared with Rt. Px in palpating Lt. upper trapezius and Lt. Rhomboids. Aware of forward shoulder posture and related tension and/or weakness.

Elbow: full active and passive ROM. Px in pronation, supination and wrist flex. All other full active and passive wrist and digit ROM with no Px.

From the pain present in pronation and wrist flexion and the elimination of digit involvement as well as the mechanism of injury (reached out to hold onto a branch while falling off of his mountain bike), I looked to treat a potential strain of the wrist flexors and was confidence in prescribing exercises and stretches to facilitate muscle healing . I knew that strengthening would be an option at this stage due to the patient reporting improvements and no recent signs of inflammation and as there was no differences in outcome from early mobilisations and immobilisation of the wrist found by Clementson, Thomsen, Jørgsholm, Besjakov, & Björkman, (2016), I was assured that this was a more progressive method to more functional outcome post the four week mark to which this research tested.

As I observed asymmetry in thoracic spine rotation by way of the seated rotation test, I used this as an objective marker to measure the effectiveness of treatment, with the aim to regain symmetrical motions where possible. As I have not seen this patient before, it was hard to know whether these restrictions were a result of his trauma, or whether they have been there, asymptomatic for a longer period of time. Regardless of this, stiffness in left rotation was evident and the patient experienced slight pain on palpating Lt rhomboids and trapezius.
I applied the following treatment:
Unilat. PA of Tx 2-4 grade 3 and grade 4. Mobs of costovertebral Jt on Lt side; grade 3 and grade 4. STM of Lt Tx, upper trapezius and rhomboids.

This was well received and I think this was due to the transparency of the treatment outcome. I was really pleased to have been able to show the patient the value of the mobilisations as he was pleasantly surprised by the significant difference in his thoracic rotation on the left side.

Because I was treating two different dysfunctions; possible strain of wrist flexors and posture of shoulders and upper body, I forgot to incorporate an objective measure for the wrist injury, the main reason for this patient’s visit. I would usually ask the patient to perform a grip strength test to compare before and after intervention, however as I did not do this, if the patient returns for a follow up assessment, I will use his reports of pain to measure progress, although this is not always the most accurate means. Ordinarily I would include an objective outcome measure for each injury but as there were two elements to this treatment, unfortunately on this occasion I missed this step.

References –

Beaudart, C., Biver, E., Bruyère, O., Cooper, C., Al-Daghri, N., Reginster, J. Y., & Rizzoli, R. (2018). Quality of life assessment in musculo-skeletal health. Aging Clinical and Experimental Research. https://doi.org/10.1007/s40520-017-0794-8

Clementson, M., Thomsen, N., Jørgsholm, P., Besjakov, J., & Björkman, A. (2016). Is early mobilisation better than immobilisation in the treatment of wrist sprains? Journal of Plastic Surgery and Hand Surgery. https://doi.org/10.3109/2000656X.2015.1137925

Hawker, G. A. (2017). The assessment of musculoskeletal pain. Clinical and Experimental Rheumatology. 35(5) S8-S12

Hawker, G. A., Mian, S., Kendzerska, T., & French, M. (2011). Measures of adult pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF. Arthritis Care and Research, 63(SUPPL. 11), 240–252. https://doi.org/10.1002/acr.20543

Picavet, H. S. J., & Hoeymans, N. (2004). Health related quality of life in multiple musculoskeletal diseases: SF-36 and EQ-5D in the DMC3 study. Annals of the Rheumatic Diseases. https://doi.org/10.1136/ard.2003.010769

Running Total of Hours: 186
External Hours: 50

In my attempts to incorporate elements of the reflective model cycle by Gibbs et al. (1988), I have found it quite difficult to use this exact template in this session because of the nature of our practice; this week lacked in any new treatments that I would fully benefit from detailed reflective analysis. I appreciate the value of a structured reflective writing and will continue to the model for reflections however, this week may not fully benefit from this means of reflection.

Patient 1 – My first patient did not arrive, so I took this opportunity once again to partner up with another student who was conducting an assessment of the lumbar spine in a patient with non-specific lower back pain. Earlier in my clinical experience, I saw many patients who presented with lower back pain and I started to feel more confident in this assessment and in managing this condition, however I have not had the opportunity to practice recently and feel as though this is an area that I need to redevelop.
I was able to work through a thorough assessment by means of range of motion, including functional combined motions and muscular control, all of which seemed as expected and bilaterally symmetrical. From my previous experiences with patients presenting with lower back pain, a generalized approach, such as core stability exercises has been most effective (Chang, Lin, & Lai, 2015).
I also found that from previous treatments, posteroanterior mobilisations provided immediate pain relief and increased ROM, as supported and recommended by (Shah & Kage, 2016; Shum, Tsung, & Lee, 2013).
Because of the comprehensive range of exercises, I posted in my reflections from earlier patients, I was able to refer to a range of options for this patient to use and I felt confident in their effectiveness. I was therefore excited to see how they would be received.
I found that by showing the patient visual guides by way of photos, before demonstrating the exercises myself, the patient was far more understanding of what was expected of them. In this instance I used my previous reflections as a reference for the patient, however in the future I will look to build a portfolio of exercises in a folder with handout sheets that I can be readily available for cases such as these.
As well as the aforementioned research on general strengthening of the glutes and erector spinae, I recently came across a study on the effectiveness of stretching the low back to help improve pain and mobility in lower back pain patients (Fernandez & A D, 2015). Because the research is increasing more focused on strengthening, I tend to leave out any stretching within prescriptions of intervention. In my research on forward shoulder posture, I have found that a combination of strengthening and stretching is the most effective means of reducing rounded shoulders and pain and improving function and range of motion but means of treating the two muscle groups (pectoralis minor and scapular muscles) to facilitate one another in their influence on posture; strengthen the scapular and thoracic region muscles but lengthen the pectoralis minor, as this also attaches to the scapular and can help allow for any kinematic alterations through exercise).
By way of a similar mechanism, but strengthening the lateral hip abductor (gluteus med., TFL) and stretching the quadratus lumborum, rectus femoris and/or hamstrings, which ever is objectively found to present with any excessive tightness, ROM of the lower back and hip may be improved.
It is important to establish which muscles are weak and which are shortened, or lengthened depending on the dysfunction and to work with this, so a thorough objective assessment is paramount in ensuring the correct program which may include the hamstrings and iliopsoas (Fernandez et al., 2015) and quadratus lumborum, erecter spinae, and TFL (Dhargalkar, Kulkarni, & Ghodey, 2017).
In future I will look to incorporate an element of both of these components into a program as a way of a more multidimensional approach.

Fortunately by the end of the session, the patient and I came up with a stretch that seemed to target the affected area. The only way to know whether this could be an effective intervention is by advising her to do this at home on a daily basis and reiterate the importance of a prolonged stretch; I always advise greater than 25 seconds as a minimal, 30 seconds gold standard. From my research, I learned of the effectiveness of passive stretching by way of muscle energy techniques (Dhargalkar, Kulkarni and Ghodey, 2017) that I could administer, should the patient return and feel as though her active stretching was ineffective. This was useful to know, as TFL stretching can be difficult at home, so I would consider incorporating an element of stretching in the allotted treatment session, not only to allow the patient to understand the benefits of stretching by way of seeing for themselves any objective lengthening or experiencing any pain relief benefits but also to facilitate their home program and ‘start them off’. But encouraging progress early on, they may feel inspired to continue their program at home.
I also suggested the use of muscle energy technique stretching if which I had not previously

Patient 2 – Previous history of impingement with new presentation of pain in thoracic spine and scapular stabilising muscles
Descriptions – This patient was a youth aged 15 and from my previous experiences of treating younger individuals, I have found that I tend to address most questions to and converse with their parent in the room, instead of the patient. I have been aware that I did this and as such I was prepared to engage fully and directly with the patient and involve the parent only when absolutely necessary and on request of the patient.
In previous appointments with young patients, I found that speaking in a simple and clear manner was especially effective to ensure that they fully understand the elements of their treatment and I even developed this further by going into a little more detail, although simply put, into our methods of treatments as she had expressed a particular interest in what I was doing.
Feelings – Although I felt confident delivering relevant tests and performing a comprehensive assessment, I still felt anxious due to the age of the patient. I still do not feel entirely confident when treating young patients due to the complexity of their growth patterns and the implications of an injury on their future in sport. In order to ensure that I was doing the very best for my patient, I conducted a thorough subjective and objective assessment before consulting the clinic manager to confirm my findings and to discuss treatment options. I felt better after gaining reassurance from the clinic manager as we had come to a similar impression of injury.
Evaluation – Overall I felt happy with my delivery of this session, although I feel as though I should be able to follow through an entire treatment at this stage in the academic year without additional advice from the clinic staff, especially with a patient displaying symptoms I regularly treat, however I am sure that the more patients I see, the more my confidence will grow. I am also aware that after this course, I may not have the opportunity to ask senior therapists’ advice and so I should fully utilise the resources while they are available to maximise my learning opportunities.
Conclusion – Despite my initial anxiety around treating a young patient, I was able to identify their injury with confidence, but also proceed with caution regarding their overall rehabilitation plan and load. Although limited, my knowledge of the differences in younger patients’ physiology was enough to identity the need to be aware and with that, I became heightened to the importance of patient education and the need to identify any ongoing risk factors that may be contributing to her pain.
Action plan – In order to gain a little more confidence in treating young people, I will take time away from the clinic to research the general physiological differences in the younger population and common injuries they may be more likely susceptible to. This will help to make me more aware of the rationale behind some treatments and the precautions that I will need to take in treatments and in prescribing rehabilitation plans.
I was aware that this 15 year old was training excessive amounts throughout the week, but before I could offer advice, I need to obtain more knowledge surrounding the effects of overtraining and periodisation of exercise programs, as well as recommended guidelines on training load.

The above was my first attempt at a structured model of reflective writing and I found it a really effective way to condense my writing into relevant sections of information and where I may have forgotten to add an action plan, this is a good reinforcement of the need for further and continued development. Although this was simple, due to the simple nature of this case, it was a good chance for me to get used to this way of reflective practice.

Patient 3 –
This was a STM for a keen runner who is currently running recreationally but who has in the past run marathons and competitions. There was no injury in this case, or the need for a detailed assessment but nonetheless I carried out a basic relevant assessment to ensure good health and wellbeing of this patient and to rule out the need for further treatment. This patient has no reports of injury and pain and simply praises the benefits felt from STM massage and as such I administered STM of various means to her hamstrings, quadriceps and calf muscles, maintaining professionalism and efficiency throughout.
The patient received the treatment well and was satisfied with her treatment.

References – 

Chang, W. D., Lin, H. Y., & Lai, P. T. (2015). Core strength training for patients with chronic low back pain. Journal of Physical Therapy Science, 27(3), 619–622. https://doi.org/10.1589/jpts.27.619

Dhargalkar, P., Kulkarni, A., & Ghodey, S. (2017). Added effect of muscle energy technique for improving functional ability in patients with chronic nonspecific low back pain. International Journal of Physiotherapy and Research. https://doi.org/10.16965/ijpr.2017.144

Fernandez, E. L., & A D, G. (2015). Efficacy of active stretching over passive stretching on the functional outcome among patients with mechanical low back pain. International Journal of Physiotherapy and Research. https://doi.org/10.16965/ijpr.2014.702

Gibbs, G. (1988). Learning by Doing: A guide to teaching and learning methods. London: Further Education Unit.

Shah, S. G., & Kage, V. (2016). Effect of seven sessions of posterior-to-anterior spinal mobilisation versus prone press-ups in non-specific low back pain-randomized clinical trial. Journal of Clinical and Diagnostic Research, 10(3), 10–13. https://doi.org/10.7860/JCDR/2016/15898.7485

Running Total of Hours – 183 hours 

Patient 1 – STM for follow up regular appointment.
During the week in our theory session for clinical experience, I had the opportunity to work through a complicated case example of an individual who, interestingly had very similar symptoms to this patient. This is my regular patient who is not able to lie prone or supine and requests STM for her upper back, neck and shoulders while in a seated position over the treatment couch. Although I have seen small improvements in her ROM, the changes have not been significant enough to improve her active daily living tasks considerably, which I have found frustrating, considering that there are many other options for treatment that I could explore.
The patient in the case study had even less ROM in her neck and shoulder to a point that she was almost unable to move her right upper side, however we worked through an action rehabilitation plan for the case study and discussed and practiced in detail, a number of exercises, many of which I made note of for this patient.
The two patients are similar in age of above 60 and predominately inactive and both do not feel able to lie either prone or supine on the treatment couch.
This patient has specific ROM deficits and restrictions in internal rotation of her L shoulder, with limited end range of motion in abduction and extension, as well as restrictions in almost all cervical movements.
However, unlike the case study she does have enough ROM to facilitate further progression of active and active assisted range and so therefore there are many more options to explore.
In this session, the patient informed me of her recent referral for an x-ray of her neck to assess the stiffness and as such she did not feel comfortable increasing her activity levels before receiving the results, which is understandable. This patient is hoping to return in the coming weeks where we can discuss these exercises and the findings of her recent imaging.

Patient 2 – Did not arrive
This patient did not turn up to their appointment, so I took the time to practice PA mobilisations on another therapist who also did not have a patient. In previous sessions I have usually performed mobilisations of the spine after STM, however after having applied the massage lotion, I have found this quite difficult. After having experienced performing PA in this session, I realised the benefit of keeping the skin dry and avoid using too much lotion when administering STM. This was yet another great opportunity to observe the way other therapists apply their techniques; quite often I find it manually very difficult and painful on my hands to apply adequate enough pressure, however when I asked my colleague to apply the technique using two separate methods, I was able to test whether either way was more or less effective and I was surprised to experience similar pressure and sensation both using the outside of the hand and the thenar eminence.
As I was amongst fellow students, I also took the opportunity to talk to them about what methods of reflective models they had been using for their reflections. I felt that findings out what works for others may be a good starting point in looking into my own ways to develop my own reflective practice. Each student I spoke to had a different idea as to the most effective methods of reflective practice, but I was guided into research developing these theories. I summarised my findings here.

Reflective Models
A definition of reflective practice, as derived by Black and Plowright:

Throughout my clinical experience and during the process of writing this reflective portfolio, I have come across a number of cases whereby I have had to first develop my understanding and basic knowledge of a concept, before even attempting to incorporate this into my practice. Initially I had very little experience with clinical practice; diagnosing and treating injuries and as such I have had to build my repertoire of skills and knowledge. Over the course of the academic year, I have found this reflective portfolio to be a very effective way to facilitate my learning and not only have I started to learn about the varying different injuries and treatment possibilities, but this has enabled me to develop and analyse strategies to use within my practice and learn how effective these can be by incorporating these into my practical element.

The importance of reflective writing is commonly reported and recommended in the development of students and in particular the use of a reflective model or framework, as found effective in a study by Greenfield et al. (2017); whereby the use of a model encouraged reflection in all 20 subjects evaluated, as opposed to just 64% of participants as found in earlier studies.
There are a number of reflective models that date back many decades but that are still used in today’s professional practice. According to Black & Plowright (2010), a multimodal approach was found to be an effective means of self-reflection and involved a combination of both written and self-dialog focusing on the 1. source of reflection; a. practice and b. learning experience, 2. target of reflection; reflection on a. learning and b. practice and purpose of reflection; to develop a. learning and b. practice.

I have found it very informative and useful developing my understanding of the practice, but this is only one element of reflective practice; being able to use this knowledge and understanding to improve my practical ability is the ultimate aim of my reflections (Black & Plowright, 2010). Because my theory and portfolio is continuous and is being completed alongside my practical application during clinic, I am able to interlink the two and do this without much conscious thought. It is therefore very important that I reflect on my practice immediately or within a certain length of time post clinic, as this will enable me to fully evaluate my performance; if I leave it too long, I will not be able to access the emotions or ideas that generate during treatments.

The model by Black and Ploughright (2010) shown above, highlights the importance of a written reflective journal, as this creates a means for stimulus and encourages the revisiting of performance. The target of reflection element refers to the level or depth of reflection, which in my case can be seen in my use of goal setting and use of writing, as this brought further analysis than self-dialog alone. It was found in this model that the written word was commonly reported as more effective than self-dialog as it encouraged added dimension to thought.
From my experience of reflections so far, I have already understood the value of the purpose of reflections from how much theory I have been able to apply into my clinical practice.

To further enhance my reflective writing, I have taken the time to discover a number of specific models, one of which was derived by Gibbs (1988) and is shown in the following flow diagram:

As well as the use of a reflective portfolio, of which I have found to be of great value in my development of learning and practice, I feel as though I have incorporated much of this cycle by Gibbs (1988) already, by good description, evaluation, analysis, conclusion and action plan, however I do not feel as though I have fully expressed my feelings in this process, the second stage of this cycle.
As a therapist who might see the same patient over a series of sessions, I am in a good position to be able to carry out any changes or utilise new strategies that I have developed through my reflective writing in future sessions with the same patient or with someone presenting with a similar injury.
this cycle demonstrates an effective means of a structured approach, to which I will look to incorporate in my future evaluations; this order will encourage my end goal of developing a strategy for any future scenarios.
My reflective writing is often long and in no particular order, so by looking to incorporate the Gibbs Cycle, most relevantly the particular subheadings;
Descriptions, Feelings, Evaluation, Analysis, Conclusion, Action plan, I may be able to condense the content to a more relevant and structured document of which I can return to for further reflective practice.

Patient 3 – This patient was new to the clinic and requested a soft tissue massage of the upper back and shoulders and was clear that no other treatment was necessary. I did ensure that I provided the patient with the appropriate advice regarding posture, as I could see from performing an objective assessment that she had forward shoulder posture. From previous treatments, I have developed a good knowledge of which exercises are appropriate, not only for patients with this posture, but for those who seem reluctant to adhere to any exercise program. I chose simple, every day type activities that the patient may feel comfortable doing without needing specialist equipment or to set aside too much time in her day.
Although I felt confident throughout the whole of this session, I did find myself becoming complacent in my professionalism and pre thinking when I asked the patient to remove her clothing. So far in the clinic I have not yet come across an individual who has felt uncomfortable removing clothing in front of me and this element of treatment did not even cross my mind in this instance, especially as she was female; I wrongly assumed that this was less of an issue. I realised that the patient felt uncomfortable as she hesitated to prepare for her massage. Fortunately I was able to recognise this immediately and I quickly offered a towel and stepped out of the cubicle until she felt comfortable and was lying supine on the couch. I too would feel uncomfortable about removing clothing in front of a therapist, so I should have been more sensitive to the patient in this instance and in future I will look to offer all patients the chance to undress either using towelling techniques or in private whereby I leave the room. The atmosphere of the clinic allows us as therapists the friendliness to feel relaxed around our clients, which I have found to be a positive part of my learning here at Marjon, however sometimes this can cause complacency in professionalism and treating each patient as individual and new arrivals, which I will look to avoid in future, not only in each patient but with each time they return to the clinic.

References –

Black, P. E., & Plowrightb, D. (2010). A multi-dimensional model of reflective learning for professional development. Reflective Practice, 11(2), 245–258. https://doi.org/10.1080/14623941003665810

Gibbs, G. (1988). Learning by Doing: A guide to teaching and learning methods. London: Further Education Unit.

Greenfield, B. H., Bridges, P. H., Carter, V., Barefoot, T., Dobson, A., Eldridge, E., … Phillips, T. (2017). Reflective Narratives by Student Physical Therapists on Their Early Clinical Experiences. Journal of Physical Therapy Education. https://doi.org/10.1097/jte.0000000000000005