22nd September Hours 1-2:
Today was our first day working in the Msk Clinic at university. Due to the recent pandemic, there has been a lot of changes in how the clinic runs. Today’s session did not consist of seeing any clients, but rather the clinic supervisors running through how our sessions will now work. They outlined all the new Covid screening precautions, which is a new set of questions to be asked before a health screening. They then also went through a case-study, through which we saw how we were now going to fill out our online clinical forms – the change from going to paper forms to online seems to be something that will take some getting used to, however the control it provides in light of the COVID-19 pandemic makes it an essential tool in completing clinic sessions for the foreseeable future.
This session highlighted to me the importance of revising my abbreviations to ensure I am able to effectively and efficiently create notes in a professional manor, whilst still ensuring the upmost detail and required information in the notes. Furthermore, I left the session wanting to do further research regarding COVID-19 and how it can present to ensure the safety of myself, my clients and the other students working in the clinic.
29th September Hours 3-4:
Our second session in the clinic was again a brief one, in which we went over another case study in preparation for our first clients the following week. This week we went into more depth in-regards-to not only the data collection and ensuring that we are confident in undergoing subjective assessments, but also in giving clients some information regarding their condition, and potentially some home-based exercises to do in the lead up to the face-to-face appointment. The case study we went over today was a lady with an achilles tendon issue. Through discussion in the group, considering her signs, symptoms and social factors, we concluded it most likely to be an achilles tendonitis.
When going through the case study, it was clear how effective it was to approach each case systematically, going over key pieces of information which can help lead to a potential diagnosis. Once we concluded a diagnosis, we discussed what exercises could be prescribed to try and provide the patient some relief in the time between the online consultation and the face-to-face appointment. This session give me good preparation for my first clients and highlighted the importance of being systemmatical in my approach to clients.
6th October Hours 4-7:
Today was our first session in clinic where we would be seeing clients. While I only had one client booked in for myself, I sat with another of the students in clinic while he had his first online consultation. This gave me a good insight of how the process would be for myself and allowed me to help the other student with his first time also. The patient was a gentleman complaining of shooting pains in his legs, with back pain also being a factor. The mans age (50 Years>) and symptoms seemed indicative of sciatica – Sciatic pain has aching and sharp components and radiates along a broad line from the middle or lower buttock, proceeding dorsolaterally in the thigh (Ropper et al., 2015). Over the online consultation we then explained the slump test to the patient, which proved to be positive for sciatica. This was enough basis to invite the patient for a face-to-face appointment the following week. To optimise treatment, we provided the client with some basic stretches such as Cat-Camels and knee to chests to begin the treatment as soon as possible. This was a good client to start with as it wasn’t difficult in terms of diagnosis and gave me a good idea of what to expect going forward.
Later on, I had my own client booked for an online consultation. Through general conversation I found out that she had injured herself through trampolining with her daughter, and landing ‘awkwardly’. This had caused a lower back pain which had since stayed and wasn’t easing off. This was a good case study to look at because while lower back pain is very common, the mechanism was not ordinary and forced me to think critically regarding my anatomical knowledge. Through conversation with the clinic supervisors, we agreed the mechanism could be indicative of a strain, but a face-to-face appointment would allow me to conduct a thorough assessment and be more confident in my diagnosis. Similarly to the first client, I demonstrated some lower back stretches to try in the time before our face-to-face appointment. Today’s clinic session was a very good insight into how we would be operating, and how interactions with a client are. It left me feeling excited for the next session and the progression that could be built with a client.
13th October Hours 7-10:
For the first part of today’s clinic session, I spent my time going over the previous weeks client notes, ensuring I had written them professionally, and that all relevant information was present. The clinic supervisors also went over the notes with myself and pointed out any small issues and explained how to amend them, which was beneficial as I will be able to spot and amend these small issues in my notes going forward. This evenings client was the person who I had an online consultation with the week previous; an initial subjective assessment shown that her symptoms had slightly improved following the exercise prescription and general management advice (Ice, Heat etc). An objective assessment of the patient found that the patient reported a ‘pulling’ sensation in extension and side flexion of the lumbar spine. The assessment helped conclude the idea that it was a strain, with the supervisor suggesting it was of the quadratus lumborum. I applied 30 minutes soft tissue massage, and also provided the client with some exercise prescription in relation to lower back stretching and strengthening. We agreed for the client to go away and try these exercises for a week and then we can re-assess her injury and make any relevant progressions/regressions. This was my first experience with a face-to-face client, and while daunting, it was a great experience and I went away from the session with a desire to widen my knowledge to ensure I can provide clients with an optimal treatment.
20th October Hours 10-14:
The first client of this evenings clinic session was a university student complaining of shin splints. The term ‘shin splints’ is used broadly to describe many conditions causing exercise induced pain in sporting personnel (Patil, 2016). The onset (running) and symptoms of the clients pain was indicative of shin splints, otherwise known as medial tibial stress syndrome (MTSS). While this client wasn’t particularly difficult to diagnose, it was my first time dealing with a MTSS case, and my lack of knowledge regarding the injury meant I could offer limited advice in how to manage the injury between this online consultation and our first face-to-face appointment. I was able to discuss it was the supervisor who offered advice to the client, but it left me feeling annoyed I had to rely on them. I concluded from the session that I needed to read up around the injury in order to be able to offer advice to any future clients who present with the same injury. I planned to read some articles/papers regarding the treatment of these injuries in runners to heighten my knowledge.
The second client was the women who presented with lower back pain in the weeks previous. The HBE prescription from our last session proved effective as the client reported a large reduction in pain after performing the exercises 4 times. As it had only been 1 week, I decided not to progress any of her exercises, but told her if she begins to find them easy then to gradually increase reps and sets until I was to see her again. 45 Minutes of soft tissue massage was also administered to the patients quadratus lumborum, rhomboids and trapezius to release any muscle tension. The client highlighted that her job was as an Occupational Therapist in the community which involved a lot of heavy lifting; this lead me to consider her job role as a potential cause for NSLBP. I decided it would be beneficial to prescribe some strengthening exercises such as RDL’s in order to increase her strength when performing these lifting movements, subsequently reducing the risk of injury.
17th November Hours 14-19:
Today I returned to clinic after 3 weeks off, due to needing to isolate from exposure to COVID-19. To ensure everyone safety, myself and the supervisors agreed I would take an extra week off. The first couple hours of my clinic session I spent going over previous patients notes, both ensuring they was written correctly and efficiently but also recapping in my mind how to write them correctly. While tedious, this was beneficial as it allowed me to feel confident and remain focused on the client and their needs. In order to try and progress as a sports therapist I will aim to use various reflective models to pick out key progression points, and ensure I correct them. Firstly I will look to use Gibbs Reflective Cycle (1988), which compromises of 6 stages; 1) Describe what happened without any conclusions at this point in time, 2) Describe your reactions and feelings during and after the experience, 3) Evaluate the situation; what was good or bad in the EDUCATIONAL RESEARCH 49 situation, 4) Analyse the situation; what sense you can make of the situation, 5) Conclude; what else could you have done in the situation, 6) Make an action plan, if the situation happened again, what would you do?.
1) My client tonight was an online consultation who presented with pain in the shoulder and neck region, which can radiate between the two. There was no clear onset and was gradual. 2)The lack of information regarding the onset and cause of the pain initially left me feeling confused, however when I thought about it in simple terms it became a lot clearer. 3) The situation was good as the client was actively seeking help for his pain and therefore was very co-operant in conversing with myself and the clinic supervisors, providing any information he deemed relevant. The situation was bad in relation to it being online, which meant I was largely limited to the information he was telling me and I couldn’t do any assessment. 4)The information he provided me suggested it was muscular tension, due to its gradual onset, lack of trauma to cause the pain and his lifestyle factors such as exercising 4/5 times a week. 5) The situation concluded by booking him in for a face-to-face appointment the following week, with the plan to perform an objective assessment of the joint and provide exercise prescription to reduce the tension. 6) My action plan for this session would be to try and perform a small assessment of the joint through the online consultation to give myself the best amount of information before seeing the client face-to-face. The use of Gibbs Model was very effective as it allowed me to consider the interaction as a whole, identify points I wish to improve on and make an action plan to apply in the future. I will aim to use reflective models going forward to maximise my potential.
24th November Hours 19-23:
For today’s reflection I will be again using Gibbs reflective cycle, going through each stage to analyse my experience and benefit from it however I can. Today’s session was the first time I had a client face-to-face who I hadn’t done an online consultation for. This presented an immediate challenge in forcing me to read the previous notes left and aim to familierise myself her injury, the onset and symptoms etc. While this was a challenge at first, it allowed me to read around the injury before seeing the client meaning I felt confident in relaying the information over. The client presented with a hallucis extensor longus tendinopathy which was confirmed through an assessment of the foot and ankle. We went through some basic HBE prescription for her to try at home, and also some soft tissue massage bilaterally for 10 minutes each leg. The change in scenario initially caused me to feel slightly anxious for the session, feeling slightly unprepared, however this forced me to read around the subject more meaning subsequently I felt better prepared than most of my other sessions previous, which highlighted the importance of further reading. Using my knowledge of tendinopathies, and the further reading I conducted I was able to highlight the need for strengthening of the surrounding muscles and subsequently was able to prescribe effective HBE. Upon reflection, to improve I could have considered other factors such as footwear which could have an impact on the injury. This would not only help the injury recover but could potentially ensure it does not come back in the future. A study by Leber et al., (1986) found that shoe insoles can reduce plantar pressure and therefore reduce subsequent injuries. This session left me with the action plan of ensuring to read around each injury I deal with in greater depth before seeing the client; this will allow me to feel more confident in discussing the injury, but also means I can provide better quality treatment.
1st December Hours 23-27:
Today was my first session where I had 2 face-to-face appointments in one evening. This would present a new challenge for myself in the form of ensuring good time management, to allow for optimum treatment time for the client, adequate time to clean and sanitize the treatment area and any equipment used, and also prepare for the next client. My first client was another client who I had not seen previous to our first face-to-face appointment. I used my experience last week and ensured I read the notes left from the clients online consultation to identify the likely diagnosis, and then read around that subject area. The first client was an individual who had visited the clinic a number of times for an ongoing facet joint issue. The aim of the session was to re-assess the movements of the lumbar spine and progress/regress the exercises accordingly. My pre-reading meant I had a good understanding going into the session regarding the type of exercise prescription that could be effective and made the situation easier for myself. The patient reported an improvement in symptoms following his previous HBE however had not been working to comment on whether the pain had improved in a functional context. Taking into considering my action plans from previous clinic sessions, I decided it would be good to still try and progress his exercises in a functional manor to ensure that when he does return to work he is pain-free. I did this by implementing more stretches and functional movements such as squats. The patient was happy with the progressions and his ROM at the lumbar spine was also improving.
After completing the notes for my first client and ensuring the equipment etc was clean, my second client was soon too arrive. I had a brief amount of time to prepare for my second client. She came to clinic with what had already been diagnosed as an achilles tendinopathy. Achilles tendon injury (tendinopathy) and pain occur in active individuals, when the tendon is subject to high or unusual load (Cook et al., 2002) which is why it is very common in runners. The client was a runner who had recently increased her distances due to beginning running with a friend; this caused a gradual onset of the pain. Using my previous reflections I aimed to manage the situation as a whole, suggesting insoles for shoes and discussing ways of still running while helping the injury recover (Softer running surfaces, shorter distances etc.). In addition to this I prescribed HBE to perform and see if they help. I finished this session feeling positive as I managed to consider my previous action points and put them into action. I will aim to use these again in the future as I would consider that my most effective session yet in-regards-to how I felt the session went.
12th January Hours 27-31:
Due to the current pandemic going on, we have been forced as a clinic to move to remote consultations for the foreseeable future. Tonight I only had a single client but spent a good amount of time before preparing, by reading around the injury (which had been identified by another student previously), ensuring my notes from previous clients were correct and creating a plan for the session. The client tonight presented with shoulder pain which arisen from a fall on the beach in which she used an outstretched arm to break her fall. She has since had pain in her shoulder which radiates into her neck. HBE which had been prescribed by a previous student reported to have a positive effect on pain, however the client is experiencing pain persistently still. The online nature of the follow up appointment was a difficult change as I am used to assessing the joint in person, so I was forced to adapt. The client was very understanding which made the situation a lot easier for myself. Me and the supervisor spent some time discussing other potential differential diagnosis and was able to rule out other injuries due to the mechanism and symptoms etc. Despite not being in person, this was a good session as it resulted in good conversation with the client that may not occur in a clinical or gym based context, which made the client more comfortable and provided myself with a lot more information regarding the clients information. This session was good as it was preparation for how the clinic will be running for the foreseeable future. While it was daunting at first, the support of the supervisors and understanding of the clients made the situation better for myself.
19th January Hours 31-35:
The ongoing pandemic, and a lack of clients has left myself little opportunity to gain clinical experience. I took it upon myself, with confirmation from my supervisors to create some exercise videos which are specific to certain injuries. Due to the last client I seen presenting with a shoulder injury, I decided to create a video containing 5 home base exercises with a focus on stretching and strengthening of the shoulder joint. Studies have shown that home based strengthening exercises are beneficial in the rehabilitation of subacromial pain syndrome and other shoulder injuries (Abdulla et al., 2015). Not only did this give me an opportunity to create a resource to use with future clients, but it gave me an opportunity to read around shoulder injuries as a topic, and the general rehabilitation principles of them. Despite being away from clinic, I still felt as though this was very beneficial for me and that I would be able to apply this knowledge in the future. I then spent a while going over the chosen exercises to ensure they would be achievable for somebody with shoulder pain, and also could be done with little to no equipment. Once recorded, I edited the video together (attached below) and was able to publish it onto my sports therapy related social media sites for clients and the public to use. This was a beneficial use of time as it got me to research in depth regarding shoulder injuries and their rehabilitation, but also made me think about how exercises can be adapted functionally to work at home, something which is very important due to the ongoing pandemic. If I was to do a similar thing again I would look to select a specific injury to provide exercises for as opposed to a whole joint; this way I can ensure I am selecting the correct exercises to optimise recovery.
https://www.instagram.com/ah_therapy/
2nd February Hours 35-39:
As we are still not able to return to the clinic due to the ongoing COVID-19 pandemic, I decided I would use my time again to create another video with some home-based exercises. Reflecting on the last one, I decided it would be more beneficial to focus on a specific injury as opposed to an entire joint, so that I can make each set of exercises more specific. Today I chose tennis elbow, as it is something that has been present in a lot of my family and friends and is very common in general. Tennis elbow is a tendinopathy of the common extensor origin of the lateral elbow; the cause of the injury varies but is commonly associated with altered loading patterns (Orchard et al., 2011). Treatment of tennis elbow is often exercise based, with an aim of stretching and strengthening the forearm muscles which attach at the lateral side of the elbow. This includes exercises such as wrist flexion and extension, towel twists and towel grips (due to the effect tennis elbow can have on grip strength). These HBE combined with good management of the load through the elbow should result in a reduction of pain. Similar to last time, I spent a while reading around the area and making sure I was choosing the best exercises for the injury, and then creating the video itself. I believe this was again a good use of my time as I am able to build a number of resources which I can use with future clients, as well as enhancing my knowledge through further reading. Going forward, I would look to create some resources which are more sport specific in relation to the prevention of injury, with a combined goal of enhancing performance.
https://www.instagram.com/ah_therapy/
16th March Hours 39-43:
After a long break, today was our first day back in the university clinic. While I had no clients of my own, I decided to pair up with 2 other students to both help them and try and learn some new things. As I am returning to clinic I am also going to try and use a new reflective model to enhance my experience; Kolb (2014) produced an experimental learning theory which suggests you learn through experience and reflective practice. This covers 4 main aspects; Concrete experience, reflection, conceptualisation, active experimentation. In todays session, I joined 2 other students in both an online consultation, and a face-to-face appointment. (Concrete experience). Being in a pair and observing how other students worked was strange initially as you can become set in a routine, whether it is effective or not. It allowed me to see how they converse with clients, as well as performing subjective and objective assessments (Reflection). This was a very beneficial session for myself despite having no clients of my own as it allowed me to view other students methods of work and apply it to my own practice (Conceptualisation). One main thing I will take away from todays session is how another student was able to make the subjective assessment a lot less formal by knowing the types of questions needing to be asked. This turned the scenario into more of a conversation which subsequently meant the client provided more information; I will look to take this approach with my next client by taking time to read the subjective assessment questions and become familiarised with them (Active Experiementation). Kolbs method of reflection was effective as it was easy to follow and gave me a clear focus for future sessions; I will use this reflective model in the future.
Tuesday 23rd March Hours 43-48:
Today’s clinic session was slightly different to usual. It began by me again pairing up with another student and helping/observing them with their client. While it was the same student, we saw a different client so it was again interesting to see how they adapted their methods according to the client. This client was significantly less talkative than the past weeks client which meant the subjective assessment was a lot more structured and less free flowing. While this is not an issue, the conversation style which was adopted last week meant the student could gain a lot more information regarding the client in an easier manor. I then spent time going over the clients notes and observed them being marked by the supervisor to see where I could potentially apply any changes to mine. The rest of the session tonight consisted of the supervisors giving a running gait analysis workshop. Gait Analysis is the systematic study of human walking (Whittle et al. 2014) and is used in the objective assessment of patients, often who present with lower limb injuries. During the session, we covered how different lower limb injuries may present in the form of a gait analysis, how to differentiate between them and subsequently, how to deal with them. While this was a different kind of session, it was very informative and made me a lot more confident in the assessment of gait, and this is something I will take with me going forward into future appointments with clients. I know that next week I have a client with a lower limb injury so before the session I will go over the information we have learnt today and aim to apply it to that client.
References:
Abdulla, S. Y., Southerst, D., Côté, P., Shearer, H. M., Sutton, D., Randhawa, K., … & Taylor-Vaisey, A. (2015). Is exercise effective for the management of subacromial impingement syndrome and other soft tissue injuries of the shoulder? A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Manual therapy, 20(5), 646-656.
Cook, J. L., Khan, K. M., & Purdam, C. (2002). Achilles tendinopathy. Manual therapy, 7(3), 121-130.
Gibbs, G. (1988). Learning by doing: A guide to teaching and learning methods. Further Education Unit.
Kolb, D. A. (2014). Experiential learning: Experience as the source of learning and development. FT press.
Leber, C., & Evanski, P. M. (1986). A comparison of shoe insole materials in plantar pressure relief. Prosthetics and Orthotics International, 10(3), 135-138.
Orchard, J., & Kountouris, A. (2011). The management of tennis elbow. Bmj, 342.
Patil, S. S. D. (2016). Shin splints. In Foot and ankle sports orthopaedics (pp. 181-186). Springer, Cham.
Ropper, A. H., & Zafonte, R. D. (2015). Sciatica. New England Journal of Medicine, 372(13), 1240-1248.