Clinical Experience Tuesday 15th October 2019 – 5.5hours

Patient 1 and 2 –
Patient 1 and 2 both reported with restrictions in shoulder ROM and associated pain and as such I was able to go through protocols with them which helped to improve my confidence in explaining and demonstrating the exercises.

These two patients, however, were very different in their subjective assessments. Patient 1 was an elderly woman who is quite inactive, whereas patient 2 was very active and significantly younger. I am comfortable identifying differences in patients; however, I find it more challenging adapting the exercises to suit their specific needs.
For my younger male patient, I was able to perform mobilisations and soft tissue massage before taking him through a session of exercises to improve strength and mobility of the shoulder joint; a treatment option supported by a number of studies including by Riaz et al. (2018) and Yildirim et al. (2016).
With the older female patient, it wasn’t possible to perform these mobilisations due to her discomfort while in lying supine or prone on the treatment couch; this patient specifically requested a soft tissue massage of her shoulders and neck only. This was a returning patient who found previous treatment of this nature effective and as such was beneficial enough to warrant a follow up treatment. However, I wanted to understand whether there were any physiological changes or measurable benefits of reducing pain and increasing ROM so that I may be able to use this method again in future patients. Sönmezer et al. (2018) found pain reduction, increase ROM and reduced tenderness in trigger points after massage, heat packs and exercises but no additional affects were noted when mobilisations were included.

Patient 3 – this patient had reported falling down the stairs ten days prior to the session and presented with pain in her ribs with some movement restrictions in thoracic and lumbar spine and her left shoulder, but there was not effusion or bruising noted from conducting my objective assessment. It became apparent from resisted movements that the latissimus dorsi and intercostal muscles were the primary affected musculature and that there was potential joint stiffness which may have been caused by the trauma and/or subsequent immobility.
The patient reported improvements but wanted reassurance that she can continue to carry out every day tasks and attend regular exercise classes, dependant on pain.
Although there was some restrictions in movement, both subjective and objective assessments revealed no obvious diagnosis and due to the ever improving nature of the symptoms and from seeking advice from my supervisor, it was decided that the best course of action was to perform mobility exercises of the thoracic and lumbar and shoulder to maintain current movements and gradually increase movements in all planes, relative to the decreasing of pain. We advised the patient to continue with physical activity but due to the more explosive nature of her exercise classes (Body Pump), we suggested that this should only be performed when pain has mostly subsided and to carry out strengthening exercises of Latissimus Dorsi and core muscles in the meantime, to support the injury site.

Patient 4 –
This patient had a history of Achilles tendon rupture, which was treated conservatively and a rehabilitation plan well adhered to. However, since returning to netball, pain has been felt in the lower back and sciatica symptoms and calf pain have occurred down the contralateral leg, which has affected motion and the patient cannot fully integrate back into training.
When performing an objective assessment, the patient had limited and painful lumbar spine extension, however I was able to identify an anterior pelvic tilt and resultant hyper lordotic curve of the lumbar spine. When I asked the patient to actively engage her gluteal and abdominal muscles, educating her on this excessive tilt, then re performing extension, the pain had subsided and range of motion was less restricted. It has previously been reported that an excessive anterior tilt of the pelvis is related to the presence of lower back pain (Król et al., 2017) and so it may be relevant that when this tilt is corrected, the pain may reduce or subside.

I felt confident that neurological tests were required due to the patient’s sciatica symptoms in order to identify lumbar disc herniation or other lumbar neuropathy and to use this as an objective measure in our treatment. The passive straight leg raise with added dorsiflexion is commonly used and in this instance it produced positive results for the reproduction of pain, however research has suggested that the reliability of this test is limited due to the similarities and difficulties in distinguishing between symptoms of other conditions such as shortened hamstring muscles and nerve root compression (Capra et al., 2011 and Sciaca et al. 2012). Although the test proved to identify possible neuropathy, whether it is nerve root compression or lumbar disc herniation, our treatment would remain the same at this stage as we felt that the possible cause of the patient’s joint stiffness and possible nerve compression may also be due to her pelvic tilt.
After performing mobilisations of the lumbar spine to treat the patient’s joint stiffness, we demonstrated a range of exercises for the patient to do at home, including bridging exercises with additional resistant bands around both lower limbs for added abduction, as his has been found to increase gluteus maximus muscle activity by 21.1% and reduce excessive anterior pelvic tilt (Choi et al., 2015).

References –

Capra, F., Vanti, C., Donati, R., Tombetti, S., O’Reilly, C., & Pillastrini, P. (2011). Validity of the straight-leg raise test for patients with sciatic pain with or without lumbar pain using magnetic resonance imaging results as a reference standard. Journal of Manipulative and Physiological Therapeutics. https://doi.org/10.1016/j.jmpt.2011.04.010

Choi, S. A., Cynn, H. S., Yi, C. H., Kwon, O. Y., Yoon, T. L., Choi, W. J., & Lee, J. H. (2015). Isometric hip abduction using a Thera-Band alters gluteus maximus muscle activity and the anterior pelvic tilt angle during bridging exercise. Journal of Electromyography and Kinesiology, 25(2), 310–315. https://doi.org/10.1016/j.jelekin.2014.09.005

Król, A., Polak, M., Szczygieł, E., Wójcik, P., & Gleb, K. (2017). Relationship between mechanical factors and pelvic tilt in adults with and without low back pain. Journal of Back and Musculoskeletal Rehabilitation. https://doi.org/10.3233/BMR-140177

Riaz F, Haider R, Qamar MM, Basharat A, Manzoor A, Rasul A, et al. Effects of static stretching in comparison with Kaltenborn mobilization technique in nonspecific neck pain. BLDE Univ J Health Sci 2018;3:85-8.

Sönmezer, e., Tüzün, e. H., Eker, l., & Yüksel, i. (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

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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