Running total of hours: 121.5

During this session, had the opportunity to carry out two initial diagnostic assessments alongside my supervisor. Before I started this academic year, my weakest area of knowledge and practical ability was by far the vertebral column, so taking up an opportunity to work for Exmoor Osteopathy was a very positive decision in the development of this area in my knowledge. The number of patients who walk through the door with back pain is vast and as such, I have been able to experience various different presentations of a wide range of spinal dysfunctions, injuries and pathologies.
According to Gordon & Bloxham (2016), between 60 and 80% of adults will have lower back pain in their lifetimes, a condition which is responsible for 12.5% of work absences and costs the NHS £1.3 million each year.
The lower back pain patients attending this clinic are usually presenting with non-specific pain, which is thought to make up 85% of all back-pain cases (Gordon & Bloxham, 2016).

Throughout the treatments of LBP in this particular clinic, conservative passive treatments such as soft tissue and joint mobilisations, manipulations and massage are most commonly performed and are evidence based to some extent, but I try to offer my thoughts on including additional rehabilitation strategies such as stretching and strengthening, as well as patient education in order to allow the patient the opportunity to manage their lower back pain more independently and without the need for continual appointments at the clinic.
Throughout my reflections I have cited many studies that provide a large body of evidence suggesting that mobilisations, manipulations and massage etc are useful in reducing pain, improving flexibility and function, however these results are often short term or have not been proved to provide benefits that are beyond transient and as such more long term exercise programs are now more commonly recommended.

In a review by Gordon & Bloxham (2016), it was concluded that exercise is beneficial for individuals suffering lower back pain, but that no one exercise was better than the other; each case should be tailored for individually and should include strengthening, stretching and cardiovascular fitness as lower back pain can be reduced by up to 76.8% by core strengthening, 20% by cardiovascular fitness at 40-60% of heart rate reserve and 58% by flexibility training of the lumbar flexor and extensor muscles.

From reading this particular review, I was interested to learn the basic role of cardiovascular exercise in the management of pain; it is thought to stimulate the production of endorphins, which alters pain perception by way of binding to opiate receptors in the brain and spinal cord. Exercise also increases blood flow and nutrients to around the body and thus to the injury sites, which enhances the healing process by way of increasing mobility and enhancing the healing process (Gordon & Bloxham, 2016).
I am always an advocate for exercise of any form, so this was another incite as to the physiology behind it and another way I can help to explain on a basic level and reinforce physical activity in my future patients who may not be as physically active as they perhaps should be.

I also came across a randomised controlled clinical trial of 109 subjects, which found kinesiology taping effective in reducing pain in non-specific lower back pain (Kelle, Güzel and Sakalll, 2016). Whether this is down to a placebo effect or not and knowing the role of perception in pain presentation, a study like this is very useful in developing a basic level of confidence in this modality and I would personally feel more comfortable suggesting this treatment in future, to facilitate further exercise rehabilitation programs.

Although I enjoyed going through the assessment process for back pain and identifying possible treatment options based on each individual presentation, as I now feel more confident approaching this, the highlight in this session was our final patient attending for a follow up appointment about her knee.
Patient overview – this patient came to the clinic with knee pain and pain radiating down the lateral aspect of her lower limb (as far as 1/3 down the leg following the course of the peroneals). This was most likely degenerative and is now causing pain in functional, every day movements. This patient is over 60 but an active walker.
Conservative treatment for the past 2 months has not been as effective as hoped; soft tissue massage, mobilisations and stretching exercises were all performed but the patient only reported minimal improvements, with little difference in pain experienced in functional movements.
Katarina, the supervising osteopath discussed the possibility of a meniscal tear and the prospect of a referral for surgery. In many areas of musculoskeletal therapy, surgery is often avoided as much as possible and conservative treatment is our most favoured option with many soft tissue injuries due to the cost of surgery, the fear of longer rehabilitation times and the adverse associated risks of surgery. However, evidence suggests that in some injuries, the earlier the surgical intervention, the better the outcome of the injury in relation to the delays in future pathology. For example, with a meniscus tear, if surgery is performed early and is successful, future degeneration can be delayed and the occurrence of osteoarthritis of the knee comes later than if surgery is not performed and as such further inevitable surgery, such as a knee replacement is put off for more longer (Vaquero & Forriol, 2016).
In order to fully assess the knee and to diagnose a meniscus injury requiring surgery, this patient would need to undergo magnetic resonance imagining (MRI), which according to Vaquero & Forriol (2016) is 90.5% sensitive and 89.5% specific or an arthroscopy which is used to both diagnose and treat via a keyhole surgical method.
The location and degree of the tear can vary the surgical treatment and there are many contraindicators that can also restrict surgical outcomes and therefore surgical intervention is not always the most suitable treatment. The cost and time involved in a referral for the patient can be extensive and as such Katarina would not suggest this lightly. The purpose of further investigations would be to identify the need for surgery or to rule out anything that may require surgery, in order to fully trust the route of conservative treatment.
A study by Kise et al. (2016), comparing the outcome of physical therapy vs. arthroscopic partial meniscectomy found no significant differences between the two options, however thigh muscle strength was found to have improved more in the conservative approach and therefore the non-surgical route is recommended, supporting earlier findings by Stensrud, Risberg and Roos (2015) in a study showing improvements in isokinetic quadriceps strength after a 12-week exercise program for the treatment of degenerative meniscus tears.
Knowing the specific criteria for surgery and effectiveness of physical therapy programs, it would usually be appropriate to continue with strengthening, however because this individual patient was not experiencing any benefits from the physical therapy, it was worth suggesting a referral.
If surgery is not indicated, we will know that we can continue to treat this patient in a conservative manor, but unlike before the referral, I will hope to add a more strengthening heavy exercise plan, rather than the more passive treatment previously administered as this provided the patient with minimal strengthening rehabilitation.

References –

Gordon, R., & Bloxham, S. (2016). A Systematic Review of the Effects of Exercise and Physical Activity on Non-Specific Chronic Low Back Pain. Healthcare, 4(2), 22. https://doi.org/10.3390/healthcare4020022

Kelle, B., Güzel, R., & Sakalll, H. (2016). The effect of Kinesio taping application for acute non-specific low back pain: A randomized controlled clinical trial. Clinical Rehabilitation. https://doi.org/10.1177/0269215515603218

Kise, N. J., Risberg, M. A., Stensrud, S., Ranstam, J., Engebretsen, L., & Roos, E. M. (2016). Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: Randomised controlled trial with two year follow-up. BMJ (Online). https://doi.org/10.1136/bmj.i3740

Stensrud, S., Risberg, M. A., & Roos, E. M. (2015). Effect of exercise therapy compared with arthroscopic surgery on knee muscle strength and functional performance in middle-aged patients with degenerative meniscus tears. American Journal of Physical Medicine and Rehabilitation. https://doi.org/10.1097/PHM.0000000000000209

Vaquero, J., & Forriol, F. (2016). Meniscus tear surgery and meniscus replacement. Muscles, Ligaments and Tendons Journal. https://doi.org/10.11138/mltj/2016.6.1.071