Clinic Monday 30th September 2019 – 4 Hours

Client 1: LBP/Lumbar disc herniation
This session was very interesting as it showed me the importance of educating the patient and ensuring that they have a full understanding of the mechanisms of their injury and as such, I felt more comfortable in questioning their reasonings behind what treatment they come into the clinic for. For example, this patient has had a history of back issues and has experienced chronic back pain of which has been treated with soft tissue therapies at the clinic. The patient requested a lower back soft tissue massage. Before treating the symptoms of pain and discomfort, a back assessment performed which identified pain in extension of the lumbar spine, more specifically when returning back to anatomical position. It was observed that the patients pelvis was tilted anteriorly, which may be closing off the joint space in the lumbar region and although his ROM was good and general fitness was excellent, it caused the patient pain and did not allow for his FROM.
This could be down to the nature of his job as a marine and the sheer weight that is carried in training exercises. It is possible, therefore that the patient has weakness and tightness in the hip flexors and glutes.
Within this session, it was necessary to perform joint mobilisations to grade I and IV to try to open up the join space over the lumbar region of the spine and to perform nutations of the sacrum.
mobilisations can be described as oscillatory movements

I found that research has been unable to show effectiveness of mobilisations on mobility and range of movement of the lumbar spine over the previous decades but reports of the effectiveness in reports of pain has been documented. Earlier research by Goodsell et al. (2000) found that posteroanterior mobilisations had no effect on the mechanics of the lumbar spine in a study of 26 participants, although there were some improvements in pain.
Stamos-Papastamos et al. (2011) conducted a study on 32 asymptomatic individuals and found no significant different in flexion and extension after posteroanterior mobilisation treatment.
Shum et al. (2013) were able to further support the positive effects of anteroposterior mobilisations on influencing pain but also reported a significant increase in active flexion and extension in their study of 20 asymptomatic subjects, also concluding that this method as highly repeatable.
In a much larger and more recent study of 75 subjects by Krekoukias et al. (2017) it was found that mobilizations were the preferred treatment for pain associated with lower back pain and disc degeneration. Basson et al. (2017) was also able to support the use of mobilisations in reducing neck and back pain within a systematic review the same year. However a year later, Coulter et al. (2018) found moderate evidence that mobilisations are less effective than manipulations or other treatment methods. These findings are useful as they are able to help me understand the rationale behind lumbar spine mobilisations in their treatment of pain and potential uses In increasing range of movement, in particular flexion and extension, although I still need to find more up to date research to further support this, due to the conflicting conclusive evidence in the aforementioned studies. It would be interesting to know if the effectiveness of the mobilisations on pain are only due to placebo effects (Goodsell et al., 2000) or whether the reduction of pain is subsequently responsible for the increase in joint range of movement and reduction in stiffness (Shum et al., 2013).

It was important to also prescribe this patient with exercises to strengthen gluteus muscles, quadricep and hamstring strength and to lengthen and strengthen hip flexors in order to better stabilise the pelvis with the goal to reduce pain in his lower back and therefore discomfort in function extension.

Client 2: Chronic ankle sprain
Overview of patient: Chronic ankle pain due to history of lateral ankle ligament injury. Patient had no diagnosis or treatment of lateral ankle sprain at time of injury but reports pain has started to increase when running.
FROM, no pain at rest, no inflammation, pain only when running.

This treatment allowed me to investigate the long lasting effects of a past untreated ankle injury and to devise an appropriate rehabilitation plan to increase strength in the ankle joint to withstand greater impact forces while running, to reduce the likelihood of reinjuring his lateral ligaments, and manage pain during functional running motions.
I understood the process of improving proprioception but wanted to understand the rational behind recommending this as a rehabilitation program, but also back this up with evidence. From the research, I found that while Schiftan, et al. (2015) highlighted the prevalence of ankle sprains, noting them to be the most common sports-related injury in their evidence review, they found proprioception programs to be effective in reducing the risk of future ankle sprains in athletes and in research by Lazarou et al.  (2018), it was determined that balance and proprioceptive neuromuscular facilitation programs are recommended to help reduce pain, improve range of motion and function of the ankle and in particular, Hanci et al. (2016) demonstrated the effectiveness of eccentric – concentric isokinetic training in improving proprioception after just a 6 week program on 13 male subjects with ankle instability.
In future, I will be able to advise the patients on specific proprioception programs based on a number of studies and be more specific in my delivery. For example, incorporate eccentric/concentric tasks, as opposed to generic activities involving uneven and unexpected surface running, such as an obstacle course or trail running.

References – 

Basson, A., Olivier, B., Ellis, R., Coppieters, M., Stewart, A., & Mudzi, W. (2017). The effectiveness of neural mobilization for neuromusculoskeletal conditions: A systematic review and meta-Analysis. Journal of Orthopaedic and Sports Physical Therapy.

Coulter, I. D., Crawford, C., Hurwitz, E. L., Vernon, H., Khorsan, R., Suttorp Booth, M., & Herman, P. M. (2018). Manipulation and mobilization for treating chronic low back pain: a systematic review and meta-analysis. Spine Journal, 18(5), 866–879.

Goodsell, M., Lee, M., & Latimer, J. (2000). Short-term effects of lumbar posteroanterior mobilization in individuals with low-back pain. Journal of Manipulative and Physiological Therapeutics, 23(5), 332–342.

Hanci, E., Sekir, U., Gur, H., & Akova, B. (2016). Eccentric training improves ankle evertor and dorsiflexor strength and proprioception in functionally unstable ankles. American Journal of Physical Medicine and Rehabilitation.

Krekoukias, G., Gelalis, I. D., Xenakis, T., Gioftsos, G., Dimitriadis, Z., & Sakellari, V. (2017). Spinal mobilization vs conventional physiotherapy in the management of chronic low back pain due to spinal disk degeneration: a randomized controlled trial. Journal of Manual and Manipulative Therapy.

Lazarou, L., Kofotolis, N., Pafis, G., & Kellis, E. (2018). Effects of two proprioceptive training programs on ankle range of motion, pain, functional and balance performance in individuals with ankle sprain. Journal of Back and Musculoskeletal Rehabilitation.

Schiftan, G. S., Ross, L. A., & Hahne, A. J. (2015). The effectiveness of proprioceptive training in preventing ankle sprains in sporting populations: A systematic review and meta-analysis. Journal of Science and Medicine in Sport, 18(3), 238–244.

Shum, G. L., Tsung, B. Y., & Lee, R. Y. (2013). The immediate effect of posteroanterior mobilization on reducing back pain and the stiffness of the lumbar spine. Archives of Physical Medicine and Rehabilitation, 94(4), 673–679.

Stamos-Papastamos, N., Petty, N. J., & Williams, J. M. (2011). Changes in bending stiffness and lumbar spine range of movement following lumbar mobilization and manipulation. Journal of Manipulative and Physiological Therapeutics, 34(1), 46–53.

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