Exmoor Osteopathy Clinic – External Placement Thursday 10th October 2019 4 hours

1. Positioning of the therapist during mobilisations
During today’s session, my supervisor was able to talk me through the techniques that she uses to perform assessments and treat patients. I often find it hard to position myself alongside my clients and as such find it manually very exhausting to carry out some manoeuvres. I was reassured that if I practiced my technique, I would be able to maintain positions and treatments for longer periods of time with more effective force and without too much strain on myself. For example, the use of my knee to carry the weight of a patient’s lower limb while performing traction of the hip, resting a patient’s arm on mine and holding them between my arm and hip so that I can use two hands when mobilising the shoulder joint, or simply moving my body when performing soft tissue massage, as opposed to putting the force through my fingers or wrists. Patient feedback provided gave me an indication that I was not able to put as much pressure on the patients and as such needed to use my body more. Throughout the treatments, I continually asked for feedback and asked the patients to compare my pressure and technique to that of my supervisor and as such was able to adjust accordingly. I found that with assistance, I was able to practice better technique and learn some invaluable body positions that I can take away into my own clinical practice.

2. Soft tissue massage before mobilisations is more effective?
It is usual practice at Exmoor Osteopathy Clinic to either perform soft tissue massage before or in conjunction with mobilisations. From experience, my supervisor has found that mobilisations and manipulations are more effective in treating joint mobility after a period of massage or in conjunction with, as a way of increasing tissue temperature and pliability.
Very little evidence is available on the effectiveness of massage on tissue and although some studies suggest that massage has no effect on the biomechanics of the gastrocnemius muscle (Thomson et al., 2015) there have also been conflicting studies to suggest that massage reduces muscle stiffness in the gastrocnemius. For example Eriksson Crommert et al. (2015) found reduction in stiffness immediately after treatment, which lasts for as little as 3minutes.
Although the latter findings show only immediate changes in muscle biomechanics, this is all that is needed for the clinician to then perform mobilisations and manipulations to the joint.
For a more fluid treatment, I will hope to combine these two treatments to maximise effectiveness when my goal is to increase ROM and reduce joint stiffness.

3. SI joint testing

One of our patients presented with lower back pain and from our subjective we included a test to identify SI Joint dysfunction (SIJD).

From the treatments that I observed, I noticed that most patients who presented with lower back or hip pain had undergone the standing flexion test, which was reported to have low reliability (von Heymann et al. 2018) and a sensitivity of 17% and a specificity of 79% (Soleimanifar et al., 2017). I am not confidence in my understanding of these terms and therefore was not able to interpret these figures, but know that they carry much importance when considering which test to use on a patient and how results must be understood and validated. I therefore carried out some further research to build upon my understanding and by doing so, I found an article explaining the terms specificity and sensitivity (Lalkhen & McCluskey, 2008).
I now better understand the limitations of a test having a sensitivity of 17%, as this means 83% of individuals with an SIJD will be left undetected. A higher specificity of 79% means that only 21% of tests will result in false positives but this doesn’t boast excellent scores and I would therefore question the test’s use when there are other motion and pain provocation tests with higher specificity and sensitivity figures. It has been recommended that pain provocation tests, particularly the gluteal irritation test was the most efficient but that the previously derived three out of five positive pain-provocation test model was the most effective when the gluteal irritation test was included, with a 93.8% sensitivity and 78.1% specificity (von Heymann et al., 2018).
Other pain provocation tests I could use in combination with the irritation test could be FABERS and the resisted abduction test, which both have 100% specificity (Soleimanifar et al., 2017).

Regardless of the reported sensitivity and specificity of the tests, the standing flexion has been a consistent objective marker of the treatment performed in the session; each time, there have been notable changes after treatment.
The session consisted of mobilisations, soft and deep tissue massage of the hips, glutes and lower back, mobility exercises and manipulations and the SIJ retested with improvements in symmetry observed.

MET stretching techniques of the surrounding hip and lower back musculature were also applied; a treatment previously found to help motor recruitment and stability (Fryer, 2011). A combination of MET stretching and exercises have been found to be effective in the treatment of SIJD (Dhinkaran et al. 2011) and as such can provide a basis in understanding of our treatment.

As well as lower lumbar spine mobility exercises, the patient was also given a series of exercises for both core stability and their glutes. It has been reported that individuals with SIJD also often presented with weakness in gluteal muscles but after a program of glute specific strengthening, experienced increased strength in their glutes and reduced lower back pain (Added et al., 2018).

References –

Added, M. A. N., de Freitas, D. G., Kasawara, K. T., Martin, R. L., & Fukuda, T. Y. (2018). Strengthening the Gluteus Maximus in Subjects With Sacroiliac Dysfunction. International Journal of Sports Physical Therapy, 13(1), 114–120. https://doi.org/10.26603/ijspt20180114

Eriksson Crommert, M., Lacourpaille, L., Heales, L. J., Tucker, K., & Hug, F. (2015). Massage induces an immediate, albeit short-term, reduction in muscle stiffness. Scandinavian Journal of Medicine and Science in Sports. https://doi.org/10.1111/sms.12341

Lalkhen, A. G., & McCluskey, A. (2008). Clinical tests: Sensitivity and specificity. Continuing Education in Anaesthesia, Critical Care and Pain, 8(6), 221–223. https://doi.org/10.1093/bjaceaccp/mkn041

M, D., A, S., & T, A. (2011). Comparative analysis of Muscle Energy Technique and conventional physiotherapy in treatment of sacroiliac joint dysfunction. Indian Journal of Physiotherapy and Occupational Therapy. An International Journal.

Thomson, D., Gupta, A., Arundell, J., & Crosbie, J. (2015). Deep soft-tissue massage applied to healthy calf muscle has no effect on passive mechanical properties: A randomized, single-blind, cross-over study. BMC Sports Science, Medicine and Rehabilitation, 7(1), 1–8. https://doi.org/10.1186/s13102-015-0015-8

von Heymann, W., Moll, H., & Rauch, G. (2018). Study on sacroiliac joint diagnostics: Reliability of functional and pain provocation tests. Manuelle Medizin, 56(3), 239–248. https://doi.org/10.1007/s00337-018-0405-6

Soleimanifar, M., Karimi, N., & Arab, A. M. (2017). Association between composites of selected motion palpation and pain provocation tests for sacroiliac joint disorders. Journal of Bodywork and Movement Therapies, 21(2), 240–245. https://doi.org/10.1016/j.jbmt.2016.06.003

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