Clinical Experience 8th October 2019 – 5.5hours

Patient 1 –
Patient Overview:
Chronically restricted neck movement, but no pain
Very RROM in all neck movements, Passive no diff; restricted in all movements, no Px just tension. R more restricted than L. Little to no ability to extend neck.
Shoulder ROM restricted, R more than L. Int. rot very restricted in L more than R (difficult to put on jacket).
Tx bilaterally equal in rotation and no Px. Lx flexion and extension ok but less than expected.
No pain on palpate of any area.
Suspected joint stiffness in Cx, and Tx in particular but unable to perform mobs due to inability to lie prone.
Tension and bulk in muscular surrounding Cx and shoulders. Patient moves shoulders instead of neck during daily, functional movements; needs to increase mobility in neck.

This patient has booked in with me next week and in preparation, I wanted to research into the best exercises to improve neck and shoulder strength and ROM. I also wanted to find research to support the use of mobilisations in helping to increase her should ROM, in particular, internal rotation so that she can find it easier to put on her jacket.

It was advised by my supervisor that a duration test may be a good indicator of neck extensor strength and as such, I should perform that In the next session to use measurements as a baseline in progress.
The Duration test consists of the contraction of the neck muscles bringing chin to chest and the length of testing is measured in seconds until the patient can no longer hold that pose. A good outcome will be to improve this time over the progression of rehabilitation.

There are a number of studies that have found cervical mobilizations to be effective in reducing myofascial pain syndrome, including that conducted by Yildirim et al. (2016) who concluded its effectiveness alongside other treatments such as soft tissue massage. Sonmezer et al. (2018), however found that treatments such as heat therapy and soft tissue massage both reduced pain in the neck, as well as increasing range of motion and associated disability but that mobilizations did not have any effect. This is useful to note with this patient, as she did not feel comfortable lying on the treatment table in a position that allows for the correct mobilisation procedures.
As this patient does not currently experience any pain associated with this limited range of movement, it is therefore appropriate to treat with soft tissue massage, stretching such as MET and exercises, as this combination has been found to improve ROM, decrease pain, improve Neck Disability Index (Ghodrati et al., 2017).

In the initial consultation, I found it difficult to assess the patient’s neck due to such limited ROM and inability to lay on the treatment table and therefore was unable to reach a proper clinical diagnosis and as such I treated the limited ROM with massage and neck active mobility exercises and suggested a stretching program. Soft tissue massage has been found to increase range of movement of the shoulder, improve function and reduce pain (Van Den Dolder & Roberts, 2003).
Based on my research, in the next session I will aim to perform more soft tissue massage and go through some more exercises to help increase neck extension and ROM.

With regards to the limited ROM in the shoulder, I will perform shoulder mobilisations in order to help most specifically with internal rotation; functionally, this is causing the patient most inconvenience when putting on items of clothing.
The glenohumeral joint capsular pattern is restriction in external rotation, followed by abduction and then internal rotation and in order to increase internal rotation, posterior glide mobilisations can be performed (Loudon et al. 2008).

Exercises such as the ‘Y’ overhead exercise for shoulder mobility can be demonstrated and performed (Liebenson & Dc, 2006) to help reduce shoulder elevation/shrugged shoulders and forward shoulder posture.

Patient 2 –
Patient overview:
P1: R 2012 full rupture of achillies and gastroc strains . P2: full rupture of achillies, torn soleus. Neither surgically repaired. L = 7/12 recovery time, R = 11/12 recovery time.

This patient presented with a history of Achilles tendon rupture in bilateral ankles and is currently undergoing rehabilitation for the reinjury of L Achilles 5 months ago.

I was interested to note that neither of these injuries were surgically treated, despite the severity of the tears. Although it is within our duty of care to rehabilitate the patients by means of the prescribed protocol or suggested program by the surgical team, I wanted to understand whether there was much difference in the outcome of each program.
In my research, I found there to be a number of studies comparing the outcomes of surgical and conservative treatment. For long term outcome and return to play, the non-operative/conservative approach has a greater rate of re-rupture and a lowered return to previous sport, whereas operative risks include infection, which was positive reinforcement for this patient.
However, although it has been found that the surgical option reduced reinjury rate (Deng et al. 2017), compared with the surgical management of other orthopaedic injuries, return to play rates after a repair is the lowest (Wang et al. 2017). This knowledge in itself led to a barrier in my own confidence with a successful outcome for this patient, as her goal was to return to activity as soon as she could.
I was able to find research suggesting that the accessibility of functional rehabilitation is more likely to contribute to conservative treatment being preferential to operative (Wu et al., 2016) and as such, reassured me that providing a functional rehabilitation program was the best we could do for this patient.

Due to currently progressing through an extensive program of rehabilitation already, this patient came in just as a means to maintain healing by way of therapeutic ultrasound (US).
Ultrasound is a commonly used practice used by clinicians in the management of sports injuries as a way of promoting the normal progression of the inflammation process and therefore normal tissue repair (Watson, 2008). In studies to support its use, Watson (2008) found that the newly formed collagen fibres after US treatment were more efficient and better orientated and that the treatment encouraged the formation of more tensile type I fibres as opposed to type III, allowing for longer lasting effects of the remodelling phase in the healing process.
In an evidence review by Eberman et al. (2013), very little evidence was found to justify its use in musculoskeletal injuries and suggested that tradition and beliefs were the motivation for its use; only effects of increased tissue temperature and possible decreases in fracture healing time were reported.
There is also little evidence to suggest optimum tissue temperatures for healing and as such, it is not possible to conclude whether heating chronic tissue has any effect on the healing process.

The patient requested this method of treatment due to past experience of a positive outcome and as such, providing the dosage is set to ensure there are no negative consequential and/or detrimental effects to the healing of the tendons, the use of this treatment was justified. The patient was also attending this session to complement a separate eccentric exercise program for rehabilitation. There is still very little evidence to support the benefits of US for tendon healing and as such I will keep up to date with future publications to support treatment of this type of injury.

Patient 3
Patient overview:
Shoulder injury from overload of work and exercise. Improving, low irritability. Chronic. Resistance band exs, can’t do press ups, definite improvement from exercises and taping.FROM, low Px around coracoid process and described as in shoulder joint during abduction and flexion and elbow flexion. very slight restriction in int.rotation.
Review of exercises, went through new ones for biceps; functional squats/lunges with weight and arms flexed – can curl bicep with resistance to progress. K-tape to R shoulder as requested.

This patient has been doing excellently throughout his rehabilitation program and was able to perform almost all movements with good range and no pain. The patient did show slight restriction in movements involving the biceps brachii. I felt confident that with my sensitive approach to the subjective and objective assessments, I was able to discuss his progress and symptoms and interpret them from a psychosocial perspective. The patient gave me a very lengthy history of his injury and reported mostly positive progress and, after going through some exercises with him, it became apparent that the pain was more likely to be more apprehension and as such, my ability to reassure him of his muscular capabilities and praise him on progress was enough to allow a huge progression in what he felt he was able to achieve; his self-efficacy.

Throughout the rehabilitation program, the patient was focusing more on the shoulder joint as a whole and putting very little force on his biceps, the area of most pain and dysfunction. In early rehabilitation, this is beneficial as it allows the strengthening of the whole shoulder joint and ability to access whole movement ranges without putting too much force through the biceps prematurely and increasing the reinjury risk, as found in a study on EMG analysis of different rehabilitation exercises for the biceps brachii muscle (Cools et al., 2014); exercises not involving bicep brachii specific movements result in much lower muscular activity than those designed to target those movements of flexion and supination.
As this patient had good range of movement and little pain throughout the shoulder joint, the progression to these bicep specific movements will prove beneficial as these would illicit the most force and muscle activity in order to build strength in this muscle.

Resistance band exercises were used initially for the early progression from isometric to isotonic strengthening with a continuous option to adjust resistance by way of band colour/strength and repetitions and sets, a method supported by Mullaney et al. (2017). This patient adhered excellently to the program and his progress has been credited to this. I felt confident that I was able to give appropriate positive feedback and encouragement throughout this session.

Patient 4 –
Patient Overview: 3/52 strain, 3x this year hx. Not properly recovered. Seeing physio, 6 weeks Rx to return to physical fitness; cross trainer 15/20mins, weighted calf raises, single leg. Started to do minimal explosive rehab. No scans, bruising/effusion at time of injury.
Foam roller, advised to have STM, physio again for 1RM exercises and trampoline 2/7. Improving, moderate irritability.
N/A, STM Only, comprehensive Rx with Army Physio, next session 2/7. Tenderness over strain during palpation, “able to palpate muscle scarring” mid region of posterior gastroc.
In process of comprehensive army rehab for recurring gastroc strain (most recent 3/52). Needs STM as maintenance to facilitate exercise sessions with occupational physio.

This patient requested a soft tissue massage of bilateral gastrocnemius muscles, as recommended by his physio. I was aware that he was undergoing a comprehensive treatment program with him occupational physiotherapist already and as such was reassured that this patient was receiving the best treatment.
I was able to perform the treatment with good strength and confidence, based on my previous experiences of soft tissue massage. I did recommend the use of a foam roller to help in the maintenance the effects of a soft tissue massage in between treatments, which I have since found to be advocated as an effective treatment by Aboodarda et al. (2015) in a randomised control study that found roller massage to effectively reduce perceived pain in muscle tender spots.
As my patient self-reported pain and tender spots, I confidently suggested this option.

References

Aboodarda, S., Spence, A., & Button, D. C. (2015). Pain pressure threshold of a muscle tender spot increases following local and non-local rolling massage. BMC Musculoskeletal Disorders, 16(1), 1–10. https://doi.org/10.1186/s12891-015-0729-5

Cools, A. M., Borms, D., Cottens, S., Himpe, M., Meersdom, S., & Cagnie, B. (2014). Rehabilitation exercises for athletes with biceps disorders and SLAP lesions: A continuum of exercises with increasing loads on the biceps. American Journal of Sports Medicine, 42(6), 1315–1322. https://doi.org/10.1177/0363546514526692

Deng, S., Sun, Z., Zhang, C., Chen, G., & Li, J. (2017). Surgical Treatment Versus Conservative Management for Acute Achilles Tendon Rupture: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Journal of Foot and Ankle Surgery. https://doi.org/10.1053/j.jfas.2017.05.036

Eberman, L., Schumacher, H., Niemann, A. J., Adams, H. M., & Kahanov, L. (2013). Research evidence for therapeutic ultrasound effectiveness. International Journal of Athletic Therapy and Training. https://doi.org/10.1123/ijatt.18.4.20

Ghodrati, M., Mosallanezhad, Z., Shati, M., Rastgar Koutenaei, F., Nourbakhsh, M. R., & Noroozi, M. (2017). The Effect of Combination Therapy; Manual Therapy and Exercise, in Patients With Non-Specific Chronic Neck Pain: A Randomized Clinical Trial. Physical Treatments: Specific Physical Therapy Journal, 7(2), 113–121.

Liebenson, C., & Dc, Ã. (2006). Self-management of shoulder disorders—Part 3.pdf. 65–70. https://doi.org/10.1016/j.jbmt.2005.10.003

Loudon, J. K. (Janice K., Swift, M., & Bell, S. (2008). The clinical orthopedic assessment guide. SciTech Book News. https://doi.org/10.1111/j.1440-6055.2007.00596.x

Mullaney, M. J., Perkinson, C., Kremenic, I., Tyler, T. F., Orishimo, K., & Johnson, C. (2017). Emg of Shoulder Muscles During Reactive Isometric Elastic Resistance Exercises. International Journal of Sports Physical Therapy, 12(3), 417–424. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/28593096%0Ahttp://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=PMC5455191

SÖNMEZER, E., TÜZÜN, E. H., EKER, L., & YÜKSEL, İ. (2018). Effectiveness of mobilization therapy for treating cervical myofascial pain syndrome. / Servikal miyofasiyal ağrı sendromunun tedavisinde mobilizasyon tedavisinin etkinliği. Journal of Exercise Therapy & Rehabilitation, 5(1), 25–32. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=sph&AN=130680661&site=ehost-live

Wang, K. C., Cotter, E. J., Cole, B. J., & Lin, J. L. (2017). Rehabilitation and Return to Play Following Achilles Tendon Repair. Operative Techniques in Sports Medicine, 25(3), 214–219. https://doi.org/10.1053/j.otsm.2017.07.009

Watson, T. (2008). Ultrasound in contemporary physiotherapy practice. Ultrasonics, 48(4), 321–329. https://doi.org/10.1016/j.ultras.2008.02.004

Van Den Dolder, P. A., & Roberts, D. L. (2003). A trial into the effectiveness of soft tissue massage in the treatment of shoulder pain. Australian Journal of Physiotherapy, 49(3), 183–188. https://doi.org/10.1016/S0004-9514(14)60238-5

Wu, Y., Lin, L., Li, H., Zhao, Y., Liu, L., Jia, Z., … Ruan, D. (2016). Is surgical intervention more effective than non-surgical treatment for acute Achilles tendon rupture? A systematic review of overlapping meta-analyses. International Journal of Surgery, 36, 305–311. https://doi.org/10.1016/j.ijsu.2016.11.014

Yıldırım, A., Akbaş, A., Dost Sürücü, G., Karabiber, M., Eken Gedik, D., & Aktürk, S. (2016). Miyofasiyal ağrı sendromuna bağlı boyun ağrılı hastalarda mobilizasyon uygulamalarının etkinliği: Randomize bir klinik çalışma. Turkiye Fiziksel Tip ve Rehabilitasyon Dergisi, 62(4), 337–345. https://doi.org/10.5606/tftrd.2016.95777

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