Clinic Experience Monday 4th November 2019 – 4 hours

Patient 1 – Follow up appointment for knee osteoarthritis – exercises and antigravity machine
Patient Overview: returning patient, last session 1 month ago. Most likely cause of medial knee pain is osteoarthritis of the L knee, aggravated by weight and recent increase in running. Previous session included the prescription of exercises to strengthen lateral hip and abductor muscles and well as quadriceps and hamstrings. Exercises included squats, single leg squats and bridges progressing these with a resistance band if pain allows.
This patient has returned to the clinic reporting of improvements pain in every day function and when performing the exercise prescription, even though his adherence to the rehabilitation exercises had been limited. Unfortunately, due to a number of home issues, the patient wasn’t able to complete his exercises daily and within the last week had not been able to complete them at all, however he had noticeable reduction in his pain levels, crediting the few exercises he did do. It is reported that the progression of osteoarthritis of the knee can be caused by muscle weaknesses (Jegu et al., 2014) so with this aim to slow down any progression of OA, reduce pain and improve function, ultimately allowing the patient to return back to running, it is important that he follows this program.
Although he had experienced a reduction of pain and increased movement from doing some of the resistance strengthening, as recommended by Smith et al. (2014) and exercises with resistance bands, as recommended by Vincent & Vincent, (2012), I was unable to progress his exercises this week to introduce more higher intensity isokinetic exercises and incorporate balance training, as found to be effective in reducing pain and increasing function (Takacs et al., 2017) as he was unable to demonstrate good technique or ability in the squats and bridges previously prescribed. It is frustrating as a therapist when an individual does not fully adhere to their rehabilitation so early on in treatment as we are therefore unable to see the potential benefits that it could have on the patient’s progress.
However, as he had returned to the clinic for a follow up appointment, that indicates some level of compliance and willingness for wanting to get better.
This session was designed to help the patient take part in some cardiovascular training which may help facilitate his return participation in running for weight loss and enjoyment purposes. However, I have since found evidence to suggest that weight loss is better achieved through reducing energy ingestion, rather than through exercise alone. A study by Westerterp (2019) on the effects of exercise on weight loss found that exercise alone proved ineffective, possible due to an increase in energy consumption through overcompensating for lost energy after exercise. Reducing energy consumption, therefore was shown as more effective, but that exercise was a useful tool to maintain any weight loss that might have occurred (Westerterp, 2019). I will advise my patient to seek dietary advice on his next visit to the clinic.
The patient opened up to me that he suffers severely from depression and finds this time of the year extremely difficult due to his past commitments to rugby and the corresponding start of the season; he is unable to play rugby now due to previous history of spine injuries. This gave me greater incentive to use the anti-gravity machine, as a way of allowing my patient to experience the joy of running, without overloading his knee in the process and aggravating symptoms and causing pain. There is a great deal of research to provide evidence in the positive physiological effects of exercise and as Osteoarthritis of the knee has been shown to cause depression and anxiety (Vincent & Vincent, 2012), creating an environment whereby the patient can exercise pain free may prove hugely beneficial to both his physical and emotional wellbeing. Exercise has been widely researched and evidence has been reported on the positive effects of exercise on mental health, including decreased anxiety, depression and stress and an increase in psychological functions; Mikkelsen et al. (2017) not only provided evidence for the aforementioned effects but also on the positive effects of exercise on inflammation, whereby decreases in inflammation have been found. This is especially relevant, as OA presents itself as an inflammatory musculoskeletal complaint.

As part of our plan that we derived after the initial consultation with the patient, weight management was a big priority as research has shown the benefits of losing weight on reducing pain in individuals with OA (Atukorala et al., 2016) and in particular at least 10% of body weight, which has been found to reduce pain and improve function (Riddle & Stratford, 2013). However, when I suggested the body composition machine to collect data to use as a clinical marker and monitor progress, his response was lacking enthusiasm and brought about a level of apprehension. Based on what he had already told me about his current and past mental health issues and as it was at a difficult time of year for the patient, I decided not to perform this test for now and re assess at the next session. My patient and I agreed that this information would not be motivational for him at this time and could affect his mental wellbeing.

In order to get my patient exercising again without irritating his knee, I looked into a number of methods of reducing load through reduced weight baring activities such as the Anti- Gravity Treadmill (AGT) and Deep Water Submersion (DWS).
Deep Water Submersion has been reported as having a similar effect of reducing weight baring load as the AGT for injury management and has also been found as an effective method to improve range of movement through resistance exercises (Patil et al., 2013). So in the absence of an AGT, this may have been effective in the early stages of rehabilitation of OA if ROM was compromised. However, as the patient does not have restricted ROM and as DWS in not effective in improving cardiovascular fitness through running due to the water resistance, I didn’t consider this option on this occasion and fully made use of the excellent facilities in the Sports Centre.

I was excited to experience the use of the AGT, as the last patient I had booked in to use this equipment did not arrive for their appointment. I needed to ask for supervisory assistance in order to learn how to use it and provide safe and effective care for my patient.

I was advised by another student to set the AGT to the lowest setting initially, so that the patient can feel the full potential effects of the equipment and gain trust in the concept of running with less gravity and as subsequently apply less loads through his knee. If the last time he ran produced pain, this may have caused apprehension to fully commit to a session on the treadmill, so giving my patient time to understand the mechanisms of the treadmill was important.
The AGT allows for the gradual increase in weight baring load (Liem et al., 2013) while maintaining cardiovascular fitness (Figueroa et al., 2011). Initially, I was able to set the treadmill at 60% of total body weight and increase the load baring weight by 5% every 8 minutes or depending on patient feedback. I wanted to find out at what level my patient could train at without the reproduction of pain. Due to a lack of research on the effects of anti-gravity training on running biomechanics and lower body kinematics, I had initially stressed the importance of reaching as higher load to train pain free as possible so as to mimic usual running loads and I wanted to minimise unnecessary issues such as a change in his running gait. However, Patil et al. (2013) found no differences in running kinematics in their subjects during their research study on the effects of ATT on knee forces.
Moreover, a study by Wang et al. (2011) on a reasonable sample size of 84 individuals with knee OA, compared the outcome of land exercises with aquatic exercises, finding no significant difference in the two programs for the reduction of pain and symptoms. This suggests that training at a lower weight baring load, in this case, may only prove to help build the patient up to normal load without aggravating symptoms, but that this training should only be temporary and inline with his own weight loss and strengthening program.

As it was the first session of cardiovascular training for at least 2 months and because he did not have his inhaler on site, my patient and I both agreed that a 20 minute session would suffice and positively, throughout this session we did not reach a weight baring limit whereby his pain was reproduced. The next session, therefore can look to further load his knee as well as allow for that much needed bought of CV exercise.

Patient 2 – Follow up appointment for sports massage
Patient overview: intense pain during palpation over C7/T1 and pain and “tightness” over upper back, shoulders and neck. Muscle bulk over affected areas and painful AROM of neck and shoulders in most movements. A history of bad news within the past two weeks. Last session of STM helped significantly, pain subsided but returned after another bout of bad news 2 days prior to session. Patient well aware of physiological responses to stress and of her won stressors and has requested a follow up treatment of more STM.

This patient had returned a week after her first session in the clinic for a STM.
My supervisor was also sceptical about the stretching prescription provided by the NHS Physiotherapist and suggested that these were of little use in general musculoskeletal therapy. Stretches are commonly prescribed and are widely incorporated in rehabilitation and treatment programs, so I was surprised by this advice and wanted to expand my own knowledge about stretching and its clinical use.
I am currently conducting my honours project/dissertation on the effects of pectoralis minor stretching on forward shoulder position and hypothesise that a simple four week program of muscle energy technique stretching will increase muscle length and alter postural alignment of the shoulder.
The title of my project is “an investigation into the effects of a 4-week Muscle Energy Technique program on pectoralis minor length in the treatment of forward shoulder posture in woman with young children”.
In writing my proposal, I came across a number of studies reporting the successes of exercise and stretching on improving shoulder and head posture and in the reduction of shoulder and neck pain, however there are few studies that differentiate between the two.
In a study by Lynch et al. (2010) on the effects of an exercise intervention on elite swimmers, found significant differences in forward head posture and shoulder pain, however the intervention program included stretching and strengthening and the positive effects could not be credited to either stretching or strengthening alone or a combination of the two.
Other research, such as that conducted by Hajihosseini et al. (2014), (Kotteeswaran et al., 2012) and M.-K. Kim et al. (2018) to name a few, also found both exercises and strengthening to be effective in reducing forward shoulder posture and reducing pain but also did not distinguish between the two.
The targeted muscle for stretching in all of the aforementioned studies was the pectoralis minor muscle. A study by Rosa et al. (2017) involved 50 participants, 25 with shoulder pain and 25 without, found that after a six weeks home stretching intervention program involving a static stretch against a wall (the same protocol I have often used in clinic), symptomatic subjects experienced a reduction in pain and an enhancement in function.
This stretch used in this study was held for one minute for four repetitions with half a minute rest periods in between (Rosa et al., 2017).
This research showed that stretching increased function and reduced pain but did not increase muscle length, supporting earlier findings by Konrad & Tilp (2014) which showed significant increase in range of motion but no structural muscle changes in 49 randomly assignment subjects.
However, it has been reported that forward shoulder position has been found to be associated with shortened pectoralis length (Finley et al., 2017) and as such it is interesting that any improvements through these stretching and strengthening programs occur, but not because of altered muscle length. A more general report in muscle extensibility has previously highlighted the differences between length and extensibility; after stretching increases in extensibility are found but may not be the result of increased muscle length but of improved sensation (Weppler & Magnusson, 2010).
The research does still encourage the use of these stretches, so I can feel confident in the prescription of these, with ROM and pain being clinical measures, not alterations in pectoralis minor length.

In my research I came across other variations of the pectoralis minor stretch to add to my repertoire for those patients who do not find the wall stretch useful or easy to do, or to add a little variation to their program. Other stretches include

Patient 3 – Follow up appointment for shoulder and thoracic spine stiffness.
Patient overview: follow-up appointment for shoulder pain and thoracic joint stiffness. Really positive feedback from previous session; pain has reduced significantly and almost not present, now full ROM of shoulder and good Lx ROM. Stiffness and restricted ROM in Tx has improved, rotation greatly improved from mobility exercises (sit on couch hands in front, twisting Tx to end range, side to side, or lunging up against wall, knee and arm ) has improved significantly in Lx but has most superiorly into T2/T3.
This patient regularly visits the clinic for STM for maintenance of shoulder pain and ROM.
This patient most recently attended the clinic for STM of shoulders and upper back and mobilisations of Tx. Soft tissue massage of the shoulder has been found to be effective in increasing range of movement of the shoulder and neck (Sefton et al., 2011) and mobilisations have also been found to improve function and reduce pain, with many studies on its effects on the lumbar and cervical spine, for example (Shah & Kage, 2016; Shum et al., 2013) so in theory, this treatment is effective in the short term.
In many of the studies on lumbar spine posterior anterior mobilisations, reduction in muscle activity of the erecter spinae has been reported as the likely reason for the increase in lumbar extension ROM, an example of which is a study by Chesterton & Payton (2017).

This shows the effects of mobilisations in treatment of the lumbar spine, however I have not been able to find any studies on the effects of mobilisations on the thoracic spine and will continue to find out more about the effects and efficacy of this treatment, as we are often using this method within the clinic to help improve thoracic ROM and reduce joint stiffness. From experience working in my external placement at Exmoor Osteopaths, by using objective markers and my improving palpating knowledge of joints I have seen improvements in ROM after mobilisations, however it is hard to be sure whether these improvements are down to the mobilisation treatment itself or the passive movements and general mobility of the patient throughout the session.

It was reassuring to know that the exercises prescribed at the previous session had provided the patient with a home program which was reported as being effective by the patient, as the shoulder has become less painful and his tolerance for higher loads gradually increased. The exercises being performed included resisted isotonic motion for the rotator cuff muscles. The band exercises, which have been shown effective by Mullaney et al. (2017) were given to the patient, specifically for external rotation, as this was slightly reduced at the first session but now back to full range on his follow up.

Overall the patient was very happy with his latest progress, but aware of the short-term nature of the on-the-day treatment he had been attending the clinic for. As he self-reports good adherence to home exercises as previously prescribed and has since experienced the benefits of this, it was by my recommendation that the patient attempts to become less reliant on this massage treatment over time and develop greater strength a function through a program of exercise as opposed to soft tissue treatment.

As well as advising the patient to continue with the shoulder strengthening that has so far been effective, with regards to his thoracic spine, I prescribed the following exercises as demonstrated by this useful video: https://www.youtube.com/watch?v=N3_3cWIuw-A

References –

Atukorala, I., Makovey, J., Lawler, L., Messier, S. P., Bennell, K., & Hunter, D. J. (2016). Is There a Dose-Response Relationship Between Weight Loss and Symptom Improvement in Persons With Knee Osteoarthritis? Arthritis Care and Research. https://doi.org/10.1002/acr.22805

Chesterton, P., & Payton, S. (2017). Effects of spinal mobilizations on lumbar and hamstring ROM and sEMG: A randomised control trial. Physiotherapy Practice and Research. https://doi.org/10.3233/PPR-160081

Figueroa, M. a., Manning, J., & Escamilla, P. (2011). Physiological Responses to the AlterG Anti-Gravity Treadmill. Journal of Applied Science and Technology.

Finley, M., Goodstadt, N., Soler, D., Somerville, K., Friedman, Z., & Ebaugh, D. (2017). Reliability and validity of active and passive pectoralis minor muscle length measures. Brazilian Journal of Physical Therapy, 21(3), 212–218. https://doi.org/10.1016/j.bjpt.2017.04.004

Jegu, A. G., Pereira, B., Andant, N., & Coudeyre, E. (2014). Effect of eccentric isokinetic strengthening in the rehabilitation of patients with knee osteoarthritis: Isogo, a randomized trial. Trials. https://doi.org/10.1186/1745-6215-15-106

Hajihosseini, E., Norasteh, A., Shamsi, A., & Daneshmandi, H. (2014). The Effects of Strengthening, Stretching and Comprehensive Exercises on Forward Shoulder Posture Correction. Physical Treatments – Specific Physical Therapy Journal, 4(3), 123–132. Retrieved from http://ptj.uswr.ac.ir/article-1-170-en.html

Kim, M.-K., Lee, J. C., & Yoo, K.-T. (2018). The effects of shoulder stabilization exercises and pectoralis minor stretching on balance and maximal shoulder muscle strength of healthy young adults with round shoulder posture. Journal of Physical Therapy Science. https://doi.org/10.1589/jpts.30.373

Konrad, A., & Tilp, M. (2014). Increased range of motion after static stretching is not due to changes in muscle and tendon structures. Clinical Biomechanics. https://doi.org/10.1016/j.clinbiomech.2014.04.013

Kotteeswaran, K., Rekha, K., & Anandh, V. (2012). Effect of stretching and strengthening shoulder muscles in protracted shoulder in healthy individuals. International Journal of Computer Application, 2(2), 111–118.

Liem, B. C., Truswell, H. J., & Harrast, M. A. (2013). Rehabilitation and return to running after lower limb stress fractures. Current Sports Medicine Reports.

Mikkelsen, K., Stojanovska, L., Polenakovic, M., Bosevski, M., & Apostolopoulos, V. (2017). Exercise and mental health. Maturitas. https://doi.org/10.1016/j.maturitas.2017.09.003

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

Patil, S., Steklov, N., Bugbee, W. D., Goldberg, T., Colwell, C. W., & D’Lima, D. D. (2013). Anti-gravity treadmills are effective in reducing knee forces. Journal of Orthopaedic Research. https://doi.org/10.1002/jor.22272

Riddle, D. L., & Stratford, P. W. (2013). Body weight changes and corresponding changes in pain and function in persons with symptomatic knee osteoarthritis: A cohort study. Arthritis Care and Research. https://doi.org/10.1002/acr.21692

Rosa, D. P., Borstad, J. D., Pogetti, L. S., & Camargo, P. R. (2017). Effects of a stretching protocol for the pectoralis minor on muscle length, function, and scapular kinematics in individuals with and without shoulder pain. Journal of Hand Therapy, 30(1), 20–29. https://doi.org/10.1016/j.jht.2016.06.006

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.2011.04.002https://doi.org/10.1249/JSR.0b013e3182913cbe

Thigpen, C. A., Lynch, S. S., Mihalik, J. P., Prentice, W. E., & Padua, D. (2010). The effects of an exercise intervention on forward head and rounded shoulder postures in elite swimmers. British Journal of Sports Medicine, 44(5), 376–381. https://doi.org/10.1136/bjsm.2009.066837

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

Smith, T., Kirby, E., & Davies, L. (2014). A systematic review to determine the optimal type and dosage of land-based exercises for treating knee osteoarthritis. Physical Therapy Reviews. https://doi.org/10.1179/1743288X13Y.0000000108

Takacs, J., Krowchuk, N. M., Garland, S. J., Carpenter, M. G., & Hunt, M. A. (2017). Dynamic Balance Training Improves Physical Function in Individuals With Knee Osteoarthritis: A Pilot Randomized Controlled Trial. Archives of Physical Medicine and Rehabilitation. https://doi.org/10.1016/j.apmr.2017.01.029

Vincent, K. R., & Vincent, H. K. (2012). Resistance Exercise for Knee Osteoarthritis. PM and R. https://doi.org/10.1016/j.pmrj.2012.01.019

Wang, T. J., Lee, S. C., Liang, S. Y., Tung, H. H., Wu, S. F. V., & Lin, Y. P. (2011). Comparing the efficacy of aquatic exercises and land-based exercises for patients with knee osteoarthritis. Journal of Clinical Nursing. https://doi.org/10.1111/j.1365-2702.2010.03675.x

Westerterp, K. R. (2019). Exercise for weight loss. The American Journal of Clinical Nutrition. https://doi.org/10.1093/ajcn/nqz070

Weppler, C. H., & Magnusson, S. P. (2010). Increasing Muscle Extensibility: A Matter of Increasing Length or Modifying Sensation? Physical Therapy, 90(3), 438–449. https://doi.org/10.2522/ptj.20090012

 

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