External Placement Exmoor Osteopathy Clinic Thursday 31st October 2019 – 4hours

Patient 1 –
Patient overview –
This patient is a regular at the clinic. He is exceptionally tall and in his initial appointment he presented with significant characteristic scoliosis throughout his thoracic and lumbar spine in particular. Over the course of his treatment, the patient has experienced improvements in his scoliosis, but having never seen this clinical presentation before, I was very interested in the long term prognosis of this condition and whether these improvements are short lived and only maintained by regular treatments or whether they could be fully corrected and the need for further treatment diminished.
I have yet been unable to find evidence to support specific musculoskeletal treatments for his condition but from patient feedback and objective markers of spinal curvature angles, obvious improvements have been made in posture, pain and function.
The curvature in the patient’s spine is not noticeable at present unless a thorough observational assessment is performed but at the beginning of his treatment over two years previous, this patient presented with sever abnormalities in his lumbar and thoracic spine.

Patient 2 –
Patient overview – pain in lateral knee and upper 2/3 of peroneal tendons. External rotation of lower leg from knee, osteoarthritis of knee
When performing unilateral hip mobilisations in order to target her SI Joint, I accidentally and unintentionally reproduced her knee pain by the way I was holding onto her foot; while holding her foot with my right hand, I was unknowingly internally rotating and abducting her leg, which closed the lateral aspect of her knee and irritated the cartilage/meniscus in the joint.
My patient kept reporting of pain in her knee but not in her lower back, the location at which I was targeting for the mobilisations, which my supervisor and I worked out to be the result of my mis movement in my right hand. Because my patient had provided me with this feedback, I was able to correct my error but also realise how important it is to control all aspects of my positioning and my hold on my patients. Because I have built a good rapport with my patients, I am able to communicate with them well and work together to find out how I can better my technique.

Because I feel as though I am lacking in a depth of knowledge on exercises and specific muscle strengthening, I wanted to discuss with my supervisor how she was currently progressing this patient with regards to a more long term treatment strategy. The soft tissue massage, mobilisations and manipulations are transient at best in this instance due to the arthritic nature of this patient’s pathology, so the prescription of exercises are paramount to the long term improvements in pain and mobility (Fransen et al., 2015; Vincent & Vincent, 2012).
It has been reported in a review by Vincent and Vincent (2012) that an individual’s biomechanics could be largely responsible for the development of knee OA and in particular, excessive rotation in the tibiofemoral joint and as this patient presented with greater external rotation of this joint in her affected knew, it would therefore be of use to consider the associated muscles. This same study found that in order to improve these adverse biomechanics, resistance training (and in particular with higher loads and fewer repetitions; six to eight repetitions of up to 80% of 1RM), to be most effective in the treatment of osteoarthritis, having boasted a number of benefits such as the increase in knee extensor and flexor strength, pain decrease and functional movements. I wanted to also note that each individual’s symptoms should be an indicator as to the intensity of exercises prescribed and that for the older population, lower intensity exercises should be considered.

My supervisor and I also discussed the Clam exercise, which is often used to strengthen the gluteus muscles and lateral abductors (Macadam et al., 2015; Willcox & Burden, 2013). My supervisor expressed her concern at the difficult nature of the exercise and the dangers of prescribing this exercise to patients who are not familiar with regular strengthening exercises or gym protocol, as there are many ways in which this can potentially be detrimental on muscular strengthening; when the gluteus Medius is not properly engaged, other structures may compensate incorrectly and the wrong muscle groups targeted, causing further imbalances (Willcox & Burden, 2013).
I have, in the past given this exercise readily to my patients, but with this in mind, I will continue to ere on the side of caution, or at least ensure that my patients have a full understanding of what they are trying to achieve when performing this exercise and to ensure that they are using the correct technique. This is important for all exercises; it is important to ask all patients to try the exercises that I demonstrate before leaving the clinic as this will enhance their understanding of the protocols.
I have been able to build on my repertoire of exercises for the gluteus muscles as there are many recent studies testing their effectiveness on improving muscular strength. A review comparing these exercises by Macadam et al. (2015) found that side lying hip abduction (the Clam), side bridge with abduction as well as standing hip abduction with a band as the most effective in activating the glute Medius muscles.
A study by Selkowitz et al., 2013 in which investigated the levels of activation in the gluteus Medius muscle in a number of abductor exercises, found that the Clam was the most effective if the sole purpose is to strengthen this muscle with minimal activation of the tensor-fascia latae (TFL); another hip abductor muscle. These findings were also later supported by another study by Bishop et al. (2018) and suggest that the clam is a specific exercise and I have not yet found evidence based research to suggest otherwise.
It is, however, beneficial as a therapist to be able to extract from this research that if there is a pathology in the TFL but that the cause maybe as a result from associated abductor tightness, the Clam exercise may prove useful in the treatment process.

Patient 3
Patient overview – This patient is an individual who returns regularly to this clinic, presenting with a number of non-specific muscular imbalances, pain and weakness as well as joint stiffness and other such pathology due to a lifetime of high impact activities and an extensive past history of traumatic injury.
Throughout her time visiting the clinic, she has experienced a significant increase in mobility and a reduction of pain, however there are still obvious deficits in ROM.
This case was interesting because she reported having fibromyalgia, a condition that I know very little about, yet can affect up to 4% of the population . I took the opportunity to better understand how this may influence the way clinicians both treat and interact with their patients.
Fibromyalgia (FM) is a condition characterised by the presence of nonlocalized musculoskeletal pain which is often present alongside other unexplained conditions associated with sleep, memory, fatigue and mood (Clauw, 2015). Fibromyalgia is thought to be caused by the over sensitivity of pain reception by way of allodynia, the increased sensitivity to pain stimuli and hyperalgesia, the heightening response to this stimuli, when compared with the general population (Clauw, 2015).
The treatment for this patient required a more holistic approach and a greater awareness of how pain is tolerated by the individual. Initially, I was applying too much pressure when performing soft tissue massage over the patient’s gluteal muscles. This area is often tender in patients, but with a heightened pain response due to FM, it is important to continually communicate with the patient to ensure that the pain is manageable and that the patient is comfortable.
Although there is a distinct lack of evidence on the effects of soft tissue massage on the treatment of fibromyalgia, a systematic review by Yuan et al. (2015) found myofascial release to be effective in reducing pain, depression and anxiety in immediate, short and long term follow ups and most other forms of massage, with the exception of Swedish massage, had a beneficial effect on symptoms.
As our patient self-reported higher levels of anxiety over the past few weeks due to a number of issues at home, a treatment of soft tissue massage would also have proved beneficial in reducing the physiological symptoms of stress. For example, a study by Bost and Wallis. (2006) in which found massage to be beneficial on an individual’s wellbeing and reduce levels of stress; the stress levels of 60 nursing subjects were reduced after receiving a 15minute massage therapy treatment once a week over a five week period.
Psychological benefits were also discussed in a study by (Poppendieck et al., 2016) investigating soft tissue massage on athletic recovery and it was proposed that although limited, there is qualitative evidence to show that massage treatment does help enhance an athlete’s perception of improvements if nothing else, which is arguably enough to justify its use within clinic, in combination of corrective and strengthening exercises.

I was confident in this treatment modality with our patient , especially when combined with additional mobility exercises and a continued strengthening exercise to take home and her positive feedback from previous sessions.

Busch et al., (2011) reported that exercise, particularly strength training and aerobic exercise has been found to improve symptoms of fibromyalgia and fitness capacity and improve quality of life. Recent research, such as that conducted by Andrade et al. (2017) also found benefits of strength training, stating it as safe and effective in reducing pain and improving sleep quality and as such is recommended in the treatment of fibromyalgia. However, the presence of pain often acts as a barrier to physical activity and as such adherence rates are low. Furthermore, females with the conditions have been reported as being less active than those of the same age but without the condition (Busch et al., 2011).. With this in mind, it was important to tailor a program that our patient will be more likely to adhere to. It may be an option to introduce more home-based exercises that can be performed away from the clinic setting, as this has also been found to improve self-efficacy and likely adherence to exercise, with the overall goal of reducing the need to return to the clinic so often and become more self-reliant in the management of her fibromyalgia symptoms.

Other: During the session I tried to practice my technique at performing soft tissue release of the gluteal muscles while using my other hand to externally and internally rotate the hip while my patient’s knee was flexed. I found it really difficult to synchronise my right and left hand and felt clumsy and not being able to apply anywhere near enough pressure. Because my patient was understanding of my learning process and the need to practice, she allowed me to continue to work on my technique until both she and I were happy that I was creating a similar movement and applying similar desired pressure as my supervisor usually performs.

References –

Andrade, A., Vilarino, G. T., & Bevilacqua, G. G. (2017). What Is the Effect of Strength Training on Pain and Sleep in Patients with Fibromyalgia? American Journal of Physical Medicine and Rehabilitation. https://doi.org/10.1097/PHM.0000000000000782

Bost, N., & Wallis, M. (2006). The effectiveness of a 15 minute weekly massage in reducing physical and psychological stress in nurses. Australian Journal of Advanced Nursing.

Busch, A. J., Webber, S. C., Brachaniec, M., Bidonde, J., Bello-Haas, V. D., Danyliw, A. D., … Schachter, C. L. (2011). Exercise therapy for fibromyalgia. Current Pain and Headache Reports. https://doi.org/10.1007/s11916-011-0214-2

Clauw, D. J. (2015). Fibromyalgia and related conditions. Mayo Clinic Proceedings. https://doi.org/10.1016/j.mayocp.2015.03.014

Fransen, M., Mcconnell, S., Harmer, A. R., Van der Esch, M., Simic, M., & Bennell, K. L. (2015). Exercise for osteoarthritis of the knee. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.CD004376.pub3

Macadam, P., Cronin, J., & Contreras, B. (2015). AN EXAMINATION OF THE GLUTEAL MUSCLE ACTIVITY ASSOCIATED WITH DYNAMIC HIP ABDUCTION AND HIP EXTERNAL ROTATION EXERCISE: A SYSTEMATIC REVIEW. International Journal of Sports Physical Therapy.

Poppendieck, W., Wegmann, M., Ferrauti, A., Kellmann, M., Pfeiffer, M., & Meyer, T. (2016). Massage and Performance Recovery: A Meta-Analytical Review. Sports Medicine, 46(2), 183–204. https://doi.org/10.1007/s40279-015-0420-x

Selkowitz, D. M., Beneck, G. J., & Powers, C. M. (2013). Which exercises target the gluteal muscles while minimizing activation of the tensor fascia lata? Electromyographic assessment using fine-wire electrodes. Journal of Orthopaedic and Sports Physical Therapy. https://doi.org/10.2519/jospt.2013.4116

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

Willcox, E. L., & Burden, A. M. (2013). The influence of varying hip angle and pelvis position on muscle recruitment patterns of the hip abductor muscles during the clam exercise. Journal of Orthopaedic and Sports Physical Therapy. https://doi.org/10.2519/jospt.2013.4004

Yuan, S. L. K., Matsutani, L. A., & Marques, A. P. (2015). Effectiveness of different styles of massage therapy in fibromyalgia: A systematic review and meta-analysis. Manual Therapy. https://doi.org/10.1016/j.math.2014.09.003

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