Clinical Experience Tuesday 29th October 2019 – 5 hours

Patient 1 –
Patient Overview: Follow-up Sports Massage Treatment. Has since seen physio who prescribed stretches for severe restrictions in all cervical spine movements and internal rotation of left shoulder.
I have seen this patient 3 times now and each time I have been unable to perform the most appropriate treatment of mobilisations

I was asked to justify my rationale behind continuing the STM treatment with my patient despite the lack of supporting evidence in its effects on ROM, if the pathology is most likely associated with the cervical spine.
As a therapy team, we suspected non-specific neck pain and cervical joint stiffness based on the severity of the patient’s restricted motion and associated end feels as well as surrounding muscle tension (Ingram et al., 2015; Loudon et al., 2008; Riaz et al., 2018).
My supervisor was very keen on encouraging the patient to allow us to perform mobilisations as he was convinced that this was our best course of action.
I did not have a clear physiological rationale as to why I would be happy to continue with STM, especially as we have seen very minimal improvements over the past 2 sessions, however I was doing all that was asked of me from my patient and I was confident that I had fully communicated our concerns about progression and the short term only benefits of STM on her condition.

A randomised, single-blind study by Ghodrati et al., (2017) found soft tissue treatment such as soft tissue release, METs and exercise prescription as effective in increasing range of motion and reducing non-specific neck pain, however a more recent original research has actually suggested that soft tissue mobilisation is not effective in improving range of motion, compared to traditionally prescribed stretching (Kompal et al., 2019) and although there were some improvements, it was not significant and only immediate effects were measured.
Further research is needed to establish whether positive effects were the result of a combination of treatment modalities, or if stretching alone is enough to encourage an increase in ROM.
It is also important to highlight the small participant sample of 24 in the study by Ghodrati et al. (2017), compared with Kompal et al. (2019), in which 50 were used.
Coulter et al. (2018) also suggested that a multimodal of treatment may be more affective in chronic lower back pain and disability than just mobilisations alone.

Riaz et al. (2018) found that both Kaltenborn method of mobilisations and static stretching have been found to increase ROM and reduce pain and this was a study on 44 subjects.
This study used a protocol whereby the patient was in a sitting position and grade three distraction mobilisations were performed for 7-10 seconds. On reading this, I initially jumped at the prospect of an effective mobilisation treatment in seated position, however, it was concluded that this method was not significantly more effective than static stretching; both were effective, improving active range of flexion by 19.8% in stretching and 22% in distraction and increasing extension by 19.5% by stretching and 22% by distraction (Riaz et al., 2018).

Patient 2 –
Patient Overview: Tennis player with rotator cuff weakness, exhibiting pain in resisted bicep flexion and resisted external rotation, with limited internal rotation.
Based on a previous history of possible rotator cuff tendinopathy and the most recent event of a pectoralis strain, a diagnosis of tendinopathy in the bicep tendon was most likely, with additional weakness in the external rotators (the posterior deltoids, infraspinatus and teres minor muscles) which was contributing to some painful movements in the Glenohumeral Joint.
As with any joint in the human body, it is not just one specific type of contraction of one muscles which causes a single plane movement, it is a combination of synergists, contracting simultaneously in multidimensional planes. Trying to isolate the exact cause of pain by identifying the weak muscle, therefore is almost irrelevant as the treatment will be the same; in this particular case, strengthening of the shoulder complex. Because I was able to identify one movement that reproduced the measurable weakness and pain, in this instance flexion and external rotation, I was able to adapt my program accordingly, focusing a little more on these movements. It is important to note how I did not focus on the prime movers of these movements, but the synergists too; treating the movement rather than the muscle.

With that said, I still felt as though my anatomy knowledge of the Glenohumeral Joint was weak and as such I spent time researching this. It is important to understand the origins of muscles to fully understand the movement capability of the joints.

I find this video of great help when visualising the individual muscles of the shoulder, but my primary source of anatomy revision in all aspects of muscles is the Trail Guide to the Body by Biel and Dom (2010), especially when trying to identify and learn the muscles as a group of movers as opposed to just their location.
In order to ensure that I do dedicate enough time for my anatomy revision, I have set aside at least 30minutes a day, focusing on one joint at a time. My plan is as follows:

Monday – Shoulder and Neck
Tuesday – Forearm, Wrist and Hand
Wednesday –Thoracic and Lumbar spine
Thursday – Hip and Upper Leg
Friday – Knee and Lower Leg
Saturday – Ankle and Foot
Sunday – Recap All

I had initially suggested the option of manual therapy by way of soft tissue massage and mobilisations, as this has been found to reduce pain (Desjardins-Charbonneau et al., 2015), however because of the transient effects of this approach and the lack of supporting evidence to suggest its effectiveness in improving function, I was told by my supervisor not to do this and to start strengthening exercises straight away. I hope to find more studies in support of soft tissue treatment and their effectiveness so that I can provide evidence based rationale to my treatment option, as from my experience, patients have been really satisfied with soft tissue treatment as a way of managing pain and mobility symptoms.

When I prescribed this patient with her exercises, I wrote down the number of repetitions and sets on her card. When reviewing what I had written, my supervisor questioned the rationale behind the relatively high repetitions but low sets. I do not have a good basic understanding of how these exercise programs are derived and could not give an evidence based answer.
According to (Ellenbecker & Cools, 2010) fifteen to twenty repetitions have previously been recommended for up to three sets of resistance training exercises as this helps to improve endurance by provoking a fatigue response of the muscles. However, the current activity levels of a patient should be considered; for example, if they are already able to function and continue with their sport, would they need to induce fatigue by high levels of repetitions or would their current activity levels be enough to do this but strength gains be missed? It may be more intuitive, therefore to increase the load and reduce the repetitions in order to maximise the efficiency of the time spent completing their rehabilitation, especially if they have not yet experienced an improvement in symptoms when just playing the sport, without additional strength training.
I have been unable to find evidence based studies to support this idea, but it was reported that lower loads of resistance exercises such as those using resistance bands are more effective than higher loads in certain exercises due to the order in which the muscles are activated; higher loads target the deltoid muscles, for example but to specifically activate the supraspinatus, lower loads should be used (Ellenbecker & Cools, 2010).
This review also recommended that rehabilitation for the rotator cuff muscles should focus on improving strength and ROM and reducing any imbalances between the internal and external rotators of the shoulder, which is particularly relevant in this patient, and then the subsequent introduction of plyometric training in the later stages (Ellenbecker & Cools, 2010).
When reflecting on the exercises I prescribed my patient, I wondered whether I had provided her with a comprehensive enough program, considering her initial functional capacity and level of tennis ability, an important consideration when designing a rehabilitation plan (Kraemer et al., 2009). I will continue to monitor progression of this patient by way of objective markers such as pain levels, onset of pain and internal rotation ROM to know whether the prescribed exercises have been effective and if not, I will adjust accordingly.
The idea of ‘periodisation’ was also mentioned and explained so that I had a basic understanding of the concept to allow me to further my knowledge on this away from the clinic, which I am continuing to do. From what I understand of periodisation, it is a very important aspect of rehabilitation, taking into account time scales of training and competition and adapting workload to reflect this, with current physical activity levels of patients and potential workload being a huge consideration in deriving a rehabilitation program. I have not been able to find enough research on this but I do know that Periodisation has a dedicated lecture coming up and therefore I can start to learn more about this in my STYH03 – Diagnostic Rehabilitation & Injury module.

Patient 3 –
Patient Overview: Plantar fasciitis
This patient was a very active runner who presented with low level discomfort in the lateral aspect of his foot, anterior to his heel by around 2cm.
After a subjective and objective assessment, it was agreed that the most likely diagnosis was plantar fasciitis, based on his sudden increase in running mileage and the characteristics of his symptoms; morning pain and stiffness that eases throughout the day, onset of pain throughout his running activities and site of tenderness being over the heel (Huffer et al., 2017; Lim et al., 2016).

I was really keen to relieve the patient’s symptoms with soft tissue treatment such as deep tissue and trigger point massage therapy of the plantar fascia and stretching and soft tissue massage of the associated muscles such as the calf and hamstrings, as tightness in these muscles have been found to increase the risk of developing plantar fasciitis (Grieve & Palmer, 2016).
However I was quickly informed that this was transient and therefore unnecessary and that I was to prescribe exercises for my patient to take home instead.
The discussion continued in the direction of our treatment integrity. As much as the short term benefits of soft tissue treatment, such as massage and mobilisations can be justified with some evidence of either physiological or psychological effects, the ethics behind this method of treatment is controversial due to the fact that it is just short term; should we as clinicians be advocating a more exercise heavy approach and be less reliant on the hands on methods?
Although I am aware of the beneficial effects of exercises and strengthening programs in the long term outcome of musculoskeletal injuries (Huffer et al., 2017), I also believe that as we have the knowledge and ability to relieve their initial symptoms, if only for a short while, it will provide the patient with a more comprehensive treatment and therefore could enhance their satisfaction and help them to feel more able to carry out their prescribed exercises thereafter by way of reduced pain and increased ROM from the soft tissue treatment.
Similarly to my earlier patient with the rotator cuff pain, in order to ensure that I am able to proceed with a more hands on approach in the clinic in future, I needed more solid rationale in order to present the clinic supervisor with better reasoning, with the hope they will allow me continue with this treatment. I wanted to find if there was any research that might suggest that a more hands on approach could at least increase patient self-efficacy and subsequently enhance adherence to rehabilitation programs.
In a study by Fraser et al. (2018) it was concluded that manual therapy does improve both function and reduces pain in plantar fasciitis and that when combined with mobilisations, exercises and strengthening, it is effective in the treatment of this condition.
I hope to be able to bring the information I have found from this recent and comprehensive systematic review into the clinic should I come across this injury again, so that I can justify my reasons of this more hands on approach.

Patient 4 –
Patient Overview: Follow up Sports Massage Appointment for treatment of upper back and pelvis pain.
In my initial assessment I discussed the level of treatment that this patient had received in the week previous. Because the usual therapist was absent due to illness, I was given this patient last minute, but wanted to maintain as much treatment continuity as possible. Fortunately I based my treatment almost solely on my own assessments, as opposed to relying on her previous notes alone, as I realised towards the end of the session that my follow up notes were those from another patient and that there was a mix up in the system; the patient I was given was not the same as my booked appointment in Cliniko, the booking software system that we use in the clinic. Bizarrely, their names and injury presentation were remarkably similar and therefore I did not pick up on the mistake until very late into the treatment.
This emphasises, not only the need to check basic patient details with the patient on their first arrival, such as their full name, but the need to be thorough in our own follow up assessment. Often it is tempting to only check if anything has changed since previous treatments and rely heavily on past assessments. Regardless of whether the patient is returning for a follow up or attending an initial appointment, if it is the first interaction between the patient and therapist, it is important to treat each treatment as though it is the first so that nothing is missed.
In this particular case, because I did conduct a more thorough assessment of the patient, instead of assuming the reliability of past notes, I feel as though I observed a potential cause to her lower back pain that was not previously recorded.
As with all patients presenting with lower back pain and after the initial range of motion tests, I assessed the patient’s lumbar spine mobility by way of the standing lumbar extension and pelvic tilt (Gondhalekar et al., 2016).
I have since learnt, however that the most accurate test for lumbar instability, as concluded by Ferrari et al. (2015) is the passive extension test with both sensitivity and specificity of 90%.
I wanted to ensure that I was fully able to perform this test in the next instance whereby lumbar spine is suspected as I can be sure of its reliability. I watched some videos of the test being performed to become more familiar with the protocol, one of which can be viewed by the following link:

As recommended by Shum et al. (2013) I performed posterior/anterior mobilisations on the lower spine, around L4/L5 to reduce joint stiffness and subsequent associated pain.

References –

Biel, A., & Dorn, R. (2010). Trail guide to the body: A hands-on guide to locating muscles, bones, and more. Boulder, CO: Books of Discovery.

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

Desjardins-Charbonneau, A., Roy, J. S., Dionne, C. E., Frémont, P., Macdermid, J. C., & Desmeules, F. (2015). The efficacy of manual therapy for rotator cuff tendinopathy: A systematic review and meta-analysis. Journal of Orthopaedic and Sports Physical Therapy. https://doi.org/10.2519/jospt.2015.5455

Ellenbecker, T. S., & Cools, A. (2010). Rehabilitation of shoulder impingement syndrome and rotator cuff injuries: An evidence-based review. British Journal of Sports Medicine, 44(5), 319–327. https://doi.org/10.1136/bjsm.2009.058875

Fraser, J. J., Corbett, R., Donner, C., & Hertel, J. (2018). Does manual therapy improve pain and function in patients with plantar fasciitis? A systematic review. Journal of Manual and Manipulative Therapy. https://doi.org/10.1080/10669817.2017.1322736

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. https://doi.org/10.32598/ptj.7.2.113

Gondhalekar, G. A., Kumar, S. P., Eapen, C., & Mahale, A. (2016). Reliability and validity of standing back extension test for detecting motor control impairment in subjects with low back pain. Journal of Clinical and Diagnostic Research, 10(1), KC07-KC11. https://doi.org/10.7860/JCDR/2016/14987.7142

Grieve, R., & Palmer, S. (2016). Myofascial trigger point therapy for plantar fasciitis: A feasibility study. Manual Therapy. https://doi.org/10.1016/j.math.2016.05.161

Huffer, D., Hing, W., Newton, R., & Clair, M. (2017). Strength training for plantar fasciitis and the intrinsic foot musculature: A systematic review. Physical Therapy in Sport. https://doi.org/10.1016/j.ptsp.2016.08.008

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

Kompal, R., Jabeen, Z., & Kashif, M. (2019). Comparison between immediate effects of soft tissue mobilization along with stretching exercises and without stretching exercises in patients with mechanical neck pain. Isra Medical Journal, 11(2), 96–100. Retrieved from https://login.ezproxy.endeavour.edu.au:2443/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=136705160&site=eds-live&scope=site

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

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

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.

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

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