03.05.19 Clinical Hours

In today’s clinic session I spent 4 hours and 30 minutes providing sport massage and shadowing graduate sports therapists going through initial assessments. I provided a sport massage to 2 patients. The first had a suspected supraspinatus tendinopathy and previous massage helped ease symptoms so I provided a STM to the right shoulder (upper trapezius, supraspinatus, levator scapula, deltoids). The second patient had tenderness in their forearms and wrists, so I provided a STM to both forearms and used MET’s and soft tissue release to remobilise the wrist flexors (Gibbons, 2011).

The first patient I shadowed came in with left hamstring complaints (34-year-old male carpenter). Objective assessment showed a -ve 90/90 hamstring tightness test even though the patient complained of tenderness and feeling of having a knot in the left hamstring. Due to this, treatment was a STM to the hamstrings (biceps femoris, semimembranosus, semitendinosus) including trigger point therapy to reduce the tenderness and muscle knots in the hamstrings and bird dog, glute bridges to strengthen the glutes, core and hamstrings.

The second patient I shadowed, came in with painful locking sensations in her neck (56-year-old female, retired). Subjective and objective assessment found that she has arthritis but not in her neck, tenderness and pain on palpation in her left upper traps and sternocleidomastoid and reduced AROM in neck side flexion and rotation. Slight forward head posture was observed. Treatment was STM to those muscles, side flexion & rotation stretches and strengthening exercises for neck flexors (chin tucks) and upper trapezius & sternocleidomastoid (isometric contractions in neck side flexion & rotation). A study by Kim (2015) looked at sternocleidomastoid (SCM) muscle activation between a forward head posture (FHP) group and control. FHP group was found to show greater imbalances between the left and right SCM, higher SCM activation in lateral flexion + rotation. They suggest that SCM was hyper activated and compensated for lack of smaller local neck muscle activation due to FHP. Finally, when assessing neck ROM in patients with FHP they suggest that clinicians take lateral flexion in the frontal plane and contralateral SCM activation into consideration in order to improve diagnosing skills. These findings back up the importance of releasing tension in the SCM and strengthening the neck muscles. Focus in future should be put on activating the smaller local neck muscles that I will have to read up on.

After the clinic session ended, I researched additional hamstring exercises to include in future rehabilitation plans and found a study by Al Attar, Soomro, Sinclair, Pappas & Sanders (2017), that found that the inclusion of the Nordic hamstring exercise (eccentric hamstring exercise) reduces the injury chance of hamstrings by 51% in the long term compared to programmes that did not include this exercise. An example of the Nordic hamstring curl is shown below.

For future reference I spent some time revising neck muscle anatomy (sternocleidomastoid, trapezius, levator scapula, scalenes) as I did not know the origins and insertions of these muscles during the clinic session (Cael, 2010). Overall, I enjoyed this session because I got to practice my manual therapy skills as well as learn valuable clinical assessment tools, that I can apply in the future such as the 90/90 hamstring tightness test. The 90/90 or lift and raise hamstring test is thought to be better than the sit and reach test which is commonly used in determining hamstring tightness. This is because the 90/90 test eliminates the effects of individual differences in arm, leg and trunk lengths which can skew results in sit and reach tests. In the 90/90 test, the hamstrings are considered tight if knee flexion remains larger than 20° when trying to extend the leg (Shimon, Darden, Martinez & Clouse-Snell, 2010). For future reference, I will do some research on whether there are any sensitivity and specificity values for this test, but for now this seems to be the best test to assess hamstring tightness.

References:

Al Attar, W., Soomro, N., Sinclair, P., Pappas, E., & Sanders, R. (2017). Effect of injury prevention programs that include the Nordic hamstring exercise on hamstring injury rates in soccer players: A systematic review and meta-analysis. Journal Of Science And Medicine In Sport20, e45. doi: 10.1016/j.jsams.2017.01.124

Cael, C. (2010). Functional Anatomy: Musculoskeletal Anatomy, Kinesiology, and Palpation for Manual therapists (1st ed.). Baltimore: Lippincott Williams & Wilkins, Wolter Kluwer.

Gibbons, J. (2011). Muscle Energy Techniques: A Practical Guide for Physical Therapists (1st ed.). Chichester: Lotus Publishing.

Kim M. S. (2015). Neck kinematics and sternocleidomastoid muscle activation during neck rotation in subjects with forward head posture. Journal of physical therapy science27(11), 3425–3428. doi:10.1589/jpts.27.3425

Shimon, J., Darden, G., Martinez, R., & Clouse-Snell, J. (2010). Initial Reliability and Validity of the Lift-and-Raise Hamstring Test. Journal Of Strength And Conditioning Research24(2), 517-521. doi: 10.1519/jsc.0b013e3181ca32ae

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