Clinic Experience Monday 28th October 2019 – 5hours

Patient 1 –
Patient Overview – Female presented with pain across lower back but more prevalent in left side. History of fall and treatment from physio and osteopaths.
Scans a year ago have revealed normal degenerative changes and was told to strengthen glutes as these were identified as an area of weakness.

From our subjective assessment, it would be understandable to arrive at the option of hip or lower back pathology, with my initial thoughts moving towards a Sacroiliac Joint dysfunction. However during my objective assessment it became apparent early on that the patient’s gluteus maximus on the ipsilateral side to her reported lower back pain was much weaker than the contralateral side.
As the gluteus maximus plays an important role in the stabilisation of the lower back by way of the erecter spinae and thoracolumbar fascia (Buckthorpe et al., 2019), it is reasonable to associate the findings of her weak gluteal muscles with her lower back pain and as such treatment to help strengthen those gluteal muscles are recommended.

A study conducted by Boren et al. (2011) derived an order of gluteal strengthening exercises by measuring EMG in 18 different exercises, ranking them from those with highest maximal volitional isometric contraction (MVIC) to the lowest; with the top exercises of a front plank hip extension recruiting the gluteus maximus at 106% MVIA, compared to the thirteenth ranked exercise of side-lying abduction with reported 51% MVIA. This table is a useful tool for clinicians, as it can be used to determine which exercises are the most appropriate to incorporate for each stage of rehabilitation and which are relevant to the level of each patients ability or adherence.

This patient lives a sedentary lifestyle, which has been reported as being a significant risk factor in developing weakness in the gluteal muscles (Buckthorpe et al., 2019). Due to these currently low activity levels and the sedentary lifestyle of the patient, I took into account her likely adherence to exercises and as such prescribed a simpler program of gluteal squeezes, which were ranked second in the aforementioned table of gluteus maximus exercises with 81% MVIA and also supported with evidence in a study by Lehecka et al. (2019).
Currently and positively, the patient was performing bridges, as instructed by another clinic. These exercises have been supported by a number of studies which found them as effective in enhancing muscle activation and endurance of the stabilizers of the spine (gluteus muscles and the hamstrings) with Boren et al. (2011) coupling this with hip extension and Youdas et al. (2015) adding an unstable surface to increase the exercise effectiveness.

Figure 1 was taken from Buckthorpe et al. (2019) and has provided me with useful visual examples of exercises that have been found to be effective in gluteus muscle strengthening.

It has also been concluded that performing glute bridges, particularly with a resistance band to facilitate hip abduction, increases gluteus maximus muscle activity significantly (Choi et al., 2015) and has therefore been recommended as an exercise to perform for gluteus maximus weakness and particularly in this study, for the treatment of an anteriorly tilted pelvis.
During this session, I did not feel confident when identifying where the muscle weakness was and needed some supervisory assistance. I am still inexperienced in identifying imbalances and perhaps more relevantly, the muscles causing the imbalances and as such I do not tend to consider this approach when carrying out my assessments. As the gluteus maximus is a global stabilizer and the largest muscle in the body, it is commonly susceptible to being a source of weakness and result in muscular imbalances (Buckthorpe et al., 2019). This could result in huge implications on an individual’s kinetic chain and become a significant risk factor of injury, therefore I will hope to make better connections between pain and muscle weaknesses in future assessments by way of enhancing my anatomical knowledge and ability to isolate and identify specific muscles within muscle groups.

Patient 2 and 3 – Non-specific shoulder pain.
My second patient was attending a follow-up appointment with me but had returned to the clinic unhappy with his progress and reporting that he had aggravated his symptoms when following his previously prescribed treatment plan. It was important to discuss the reasons for this set back and understand why this may have happened.
In the previous session, it became apparent that the patient may have limitations in progression to more function bicep movements by way of apprehension rather than physiological symptoms. This patient reported very little in the way of pain and had no clinical signs suggestive of an injury, however he still felt unhappy with his progress.
My patient and I both agreed that my enthusiasm towards his progression was perhaps a little too much and could have been misinterpreted. I wanted to instil confidence in my patient that he was physiologically able to perform bicep exercises, however my patient felt as though I gave him too much confidence which led to him over exercising and pushing himself too far, subsequently causing his pain to return and increase.
It has been previously stated in a review by Podlog et al. (2011) that athletes who are anxious about re injuring themselves when returning back to sport are more likely to re injure themselves and although some individuals may be physiologically ready to play in terms of pain and range of motion, they may need more time to fully appreciate their functional ability and progress in their rehabilitation. Interestingly, this patient seemed to have jumped from high levels of reinjury anxiety to overloading the tissues due to his determination to return to his previous level of activity with my enthusiasm for his progress, possibly being a major contributing factor. A report by Kraemer et al. (2009) recommended that athletes be properly educated on the physiological processes of injury recovery as a way of reducing the risk of overtraining, however due to the anxieties of my patient and reinjury rate, I was apprehensive about explaining this to him in too much depth.
This report also highlighted the need for everyone involved in the rehabilitation process to fully agree on the progression and processes involved in rehabilitation and by me exerting too much confidence on my patient, I may have overridden his natural will to over train (Kraemer et al., 2009). As recommended by (Blanchard & Glasgow, 2014), regression of some exercises in rehabilitation can be needed to ensure that the overall program outcomes are met. With this in mind, at the end of the session, the patient and I both agreed to change the current program, stop certain aggravating exercises (bicep resistance exercises) and introduce these functional progression exercises more gently at a later stage in the program, to prevent any overloading of tissues and take into account the psychological barriers that may be present.
My third patient also presented with shoulder pain, which I treated in a very similar manor to my previous patient, implementing a similar rehabilitation strategy and prescribing similar exercises. This patient, however, was part of the McMillians Cancer Program.
This is the first encounter that I have had with a patient who has had or is undergoing treatment for cancer. At times during the session, I felt as though I did not have enough basic knowledge of the pathology to be able to understand a lot of what he was saying and I felt uncomfortable not being able to fully engage in the conversation.
I know that throughout my career as a sports therapist, I will come across many patients with a wide range of ailments, pathologies and disorders that are well beyond my knowledge capacity and expected scope of understanding. I need to accept that I can engage in a conversation with my patients and maintain empathy for them, even without knowledge or understanding of their condition.
I can expand my knowledge by asking questions when appropriate and in a sensitive manor. By showing interest in their personal experiences, I will hope that they feel listened to.

Patient 4 –
Patient overview – Initial Appointment for lower back pain
There is little evidence documenting the effectiveness of soft tissue massage for the treatment of soft tissue injuries and although a study by Sefton et al. (2011) on neck and shoulder massage found improved cervical ROM in all movements, the study was limiting, having only included sixteen subjects. This study also found only short term effects and anything after this was beyond the scope of the research and are therefore not useful findings in the treatment of chronic issues.
Although in a comprehensive review by Farber & Wieland (2016) involving 3096 participants, whereby soft tissue massage alone has been found to be an ineffective treatment option for more than just short term relief in lower back pain, there were other previous and original studies that have found it to be effective (Kumar et al., 2013) and some that have found massage as useful when used in conjunction with other treatments such as exercises
There may not be enough evidence for the effectiveness of massage alone in the treatment of soft tissues injuries where there is a mechanical cause of the pain and in this case it may be due to his excessive lumbar lordosis and anterior pelvic tilt.
By using massage as a way of increasing muscle temperature and blood flow (Gasibat & Suwehli, 2017), it may be a useful intervention before the movement and mobilisation of the joint; a possible way to reduce muscle guarding and or stiffness.

Mobilisations, however, have also been the subject of conflicting evidence, with some early studies suggesting that posteroanterior mobilisations did not contribute to mechanical adaptations of the lumbar spine (Goodsell et al., 2000), however it has been found to help relieve pain and increase range of motion in a more recent study by Shum et al. (2013).
Similarly to massage, a combination of modalities are recommended by Shah & Kage (2016) in a study concluding that although effective on their own, both posteroanterior mobilisations and prone press up exercises together are effective in reducing lumbar spine pain, improving lumbar extension and function. Coulter et al. (2018) also suggested combining treatments as this review found only moderate evidence of limited effects of mobilisations alone.
I prescribed this patient with a series of exercises to help improve his posture and excessive anterior pelvic tilt. These exercises included glute bridges with a resistance band to encourage isometric hip abduction (Choi et al., 2015) and mobility exercises for his lumbar spine to encourage and increase ROM.
Throughout my time in the clinic, I have seen a number of patients presenting with lower back pain, which is can often associated with, if not caused by an anterior pelvic tilt (Choi et al., 2015).
I am aware of this in my own posture and I too experience that lower back pain as a result, so know the importance of educating individuals about their posture and the need to strengthen their gluteal muscles, however I find it difficult to approach this subject; I have yet to find a subtle, yet informative way to tell a patient that they “stick their bottoms out”. I am sensitive to the nature of this subject and the implications that this may have on an individual’s self-esteem, due to common societal opinion but from research, for example by (Kim et al., 2015) on 88 students, exercises were found to correct postural malalignments and subsequent pain in shoulders, mid back and lower back.

References – 

Blanchard, S., & Glasgow, P. (2014). A theoretical model to describe progressions and regressions for exercise rehabilitation. Physical Therapy in Sport, 15(3), 131–135. https://doi.org/10.1016/j.ptsp.2014.05.001

Buckthorpe, M., Stride, M., & Villa, F. Della. (2019). Assessing and Treating Gluteus Maximus Weakness – a Clinical Commentary. International Journal of Sports Physical Therapy, 14(4), 655–669. https://doi.org/10.26603/ijspt20190655

Boren, K., Conrey, C., Coguic, J. Le, Paprocki, L., & Voight, M. (2011). Ijspt-06-206. 6(3), 206–223.

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

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. https://doi.org/10.1016/j.spinee.2018.01.013

Farber, K., & Wieland, L. S. (2016). Massage for Low-back Pain. Explore. https://doi.org/10.1016/j.explore.2016.02.014

Ingram, L. A., Rivett, D. A., & Snodgrass, S. J. (2015). Comparison of cervical spine stiffness in individuals with chronic nonspecific neck pain and asymptomatic individuals. Journal of Orthopaedic and Sports Physical Therapy, 45(3), 162–169. https://doi.org/10.2519/jospt.2015.5711

Kim, D., Cho, M., Park, Y., & Yang, Y. (2015). Effect of an exercise program for posture correction on musculoskeletal pain. Journal of Physical Therapy Science, 27(6), 1791–1794. https://doi.org/10.1589/jpts.27.1791

Kraemer, W., Denegar, C., & Flanagan, S. (2009). Recovery from injury in sport: Considerations in the transition from medical care to performance care. Sports Health, 1(5), 392–395. https://doi.org/10.1177/1941738109343156

Kumar, S., Beaton, K., & Hughes, T. (2013). The effectiveness of massage therapy for the treatment of nonspecific low back pain: A systematic review of systematic reviews. International Journal of General Medicine. https://doi.org/10.2147/IJGM.S50243

Lehecka, B. J., Turley, J., Stapleton, A., Waits, K., & Zirkle, J. (2019). The effects of gluteal squeezes compared to bilateral bridges on gluteal strength, power, endurance, and girth. PeerJ, 7, e7287. https://doi.org/10.7717/peerj.7287

Gasibat, Q., & Suwehli, W. (2017). Determining the Benefits of Massage Mechanisms: A Review of Literature. Article in Journal of Rehabilitation Sciences, 2(3), 58–67. https://doi.org/10.11648/j.rs.20170203.12

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. https://doi.org/10.1067/mmt.2000.106867

Podlog, L., Dimmock, J., & Miller, J. (2011). A review of return to sport concerns following injury rehabilitation: Practitioner strategies for enhancing recovery outcomes. Physical Therapy in Sport, 12(1), 36–42. https://doi.org/10.1016/j.ptsp.2010.07.005

Sefton, J. E. M., Yarar, C., Carpenter, D. M., & Berry, J. W. (2011). Physiological and clinical changes after therapeutic massage of the neck and shoulders. Manual Therapy. https://doi.org/10.1016/j.math.2011.04.002

Shah, S. G., & Kage, V. (2016). Effect of seven sessions of posterior-to-anterior spinal mobilisation versus prone press-ups in non-specific low back pain-randomized clinical trial. Journal of Clinical and Diagnostic Research, 10(3), 10–13. https://doi.org/10.7860/JCDR/2016/15898.7485

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. https://doi.org/10.1016/j.apmr.2012.11.020

Youdas, J. W., Hartman, J. P., Murphy, B. A., Rundle, A. M., Ugorowski, J. M., & Hollman, J. H. (2015). Magnitudes of muscle activation of spine stabilizers, gluteals, and hamstrings during supine bridge to neutral position. Physiotherapy Theory and Practice. https://doi.org/10.3109/09593985.2015.1010672

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