Running total of hours: 146

Patient 1 – STM and maintenance of fibromyalgia patient
As this was the second time I have encountered this patient, I was much more aware of the presentation and nature of fibromyalgia and as such I felt more confident in delivering a safe and effective treatment that required sensitivity of the patient’s physical and psychological needs.
I knew to communicate wit the patient to gain continued feedback on how the patient was feeling, and although this is usual practice, in this instance, it was even more important to ensure that I was not exasperating the patient’s pain.
I am relatively strong and have always felt the need to perform soft tissue treatment with much force and I often try to apply too much pressure as a result of this, however after a discussion on my practical application of sports massage, Kat suggested that I do not need to use so much pressure, but to take each individual differently; it is more the patient’s tolerance and also need for tissue mobilisation. Instead of just giving a generic sports massage, it is important to feel the individual’s muscle tension and requirements and massage accordingly and this is something I often do not consider. I feel that sometimes I become too complacent when performing soft tissue treatments as I do this on a regular basis and feel proficient at this and as such requires less thought. However, this complacency may be affecting my ability to provide a treatment that is specific to the individual and I should refer back to my rationale of treatment.
This patient benefits hugely from a more gentle approach and with low muscle tone, it is important to apply massage with gentle pressure.

Patient 2 – Scoliosis –
This patient was a regular at the clinic, receiving maintenance and review sessions for the continued treatment for scoliosis.
Earlier in my practical clinic experience, I encountered an individual who was likely to have a slight scoliosis in his spine, however the degree of his curvature probably fell short of a clinical diagnosis of scoliosis (Cheng et al., 2015). This patient was around 15 years older, but had received a clinical diagnosis at a younger age and presented with a greater degree of curvature and a much more obvious curve.
I was able to ask many questions about her experience of the condition and the options that were given to her at a much earlier age than my previous patient.
I found this case especially interesting as the patient had a brother, who had scoliosis to an even greater degree.
As the diagnostic criteria and subsequent treatment for scoliosis is determined by the degree of curvature, it is likely that this patient’s curve did not warrant surgery at the time of assessment when she was thirteen due to the likely low risk of progression for individuals with curvature less than 20 degrees, however her brother’s curve probably did exceed 20 degrees, although the degree of her brother’s curve was unknown to the patient (Trobisch, Suess and Schwab, 2010).
Because of the prospect of a genetic element to this case, the siblings were approached to be involved in research, however this was not materialised and still today, little evidence has been published on the inherent aspect of this condition. However it has been highlighted in a review that genetics probably do present as a possible factor, with up to 70% chance of scoliosis presentation of monozygotic twins (Trobisch et al., 2010). Unfortunately I did not ask the patient if her brother was her identical twin, but he is a relative at least.

The patient found the information that I had learnt from my previous reflections interesting and had given her a small insight into her condition, however I was shocked when she explained that she had never looked into the condition. When talking with patients about research I am careful to cite only reliable sources, so as not to provide false or unreliable information, especially when it may change their course of treatment or rehabilitation focus or motivation. I also make sure that the patient knows to conduct their own research on the subject to further expand their knowledge, because patient education is one of the most important elements to successful rehabilitation adherence in physiotherapy type treatments (Bassett, 2015). I am also careful to ensure that they too learn from reliable sources and remain open minded.

This patient’s brother did undergo the surgery to correct his spine, which provided a successful outcome and the curve is no longer present, however he still experiences the same pain as before of which is of a similar degree to his sister, even though she did not undergo surgery; the only difference between the two individuals is now the aesthetic spinal deformity, which does not seem to cause an issues for the sister.

When taking into account psychological issues that may arise from this abnormal shaped spine and the probability of progression in more obvious curves, it is understandable why some adolescents undergo surgery, but as I have seen in this case, it is not always the most effective in the treatment of pain and the management is usual conservative throughout their lives, hence the continued visits to the clinic.

As I am experiencing with my young male patient in the clinic, I strongly believe that educating the patient on the best exercises to perform at home is the best course of action to develop their own ability to maintain their strength and reduce pain associated with any muscle imbalances. From my understanding of this particular patient and her current rehabilitation plan, the focus is not on exercise or exercise education, but on a repeated cycle of soft tissue manual therapy and although this can be effective in facilitating rehabilitation, it may not provide the patient with long term benefits. If this was my patient in my own setting, I would start to decrease her reliance on the soft tissue passive therapy and keep this to a minimum as per her request, but schedule in regular gym sessions whereby our attentions are on strengthening of the weakened or lengthened areas affected by the curvature.

Patient 3 – Back Pain; considering hypermobility
The final patient due to attend the clinic during this session was unable to make her appointment and therefore I had an hour in which to practice any skills I have learnt or to talk through elements of practice with my supervisor.

Throughout my studies into sports therapy, I have rare has the opportunity to be the patient and as such do not know what it feels like to be on the receiving end of the assessment and when Kat suggested performing an assessment of my back, I took that as a fantastic opportunity to experience what my patients experience, as well as continued discussion on the findings of my lower back assessment.
I learnt a considerable amount from my experience of being the patient. One of the first things I experienced was the nature of physical contact; I find it uncomfortable with physical contact from others and although this was an environment within which I was clearly consenting to a physical assessment, it still came as a shock when Kat put her hands on my lower back and hips and I felt quite uncomfortable. This is what I do every time I see a patient and have to use a hands on approach with my assessments, however I never think to consider constant reassurance and communication as to my actions. I now know that it may just be good practice to reassure my patient of my intentions to place my hands on them and also explain to them in more of a step by step manor.

Patient Overview: Constant lower back ache 3/10 for at least 6 years, previous trauma to back 15 years ago after falling from horse onto a curb.
Recurrent severe lower back spasms that last for up to 10seconds sporadically throughout the day for up to 3 days at it’s worse, improves after 7 days on average.
Often comes on after running and having sat down but this occasion the onset was gradual over one week.
Spasms cause leg muscle weakness and pins and needles when sitting. No indication of root involvement from assessment.
Cannot flex or extent Lx, unable to stand straight and can only lean to right side (Pt slight forward flex and right side flex only comfortable position when walking).
muscle guarding causing severe muscle spasms, particularly in pelvic movements.
At present, Pt noticing improvements but still cannot straighten lower back.
Generally hyper mobile joints, stiffness in Lt SI joint, could not manipulate. Coccyx pain constant; feels like it’s “bruised”.

In this instance, it was hard to perform a thorough assessment as the muscle spasms were so acute and I was apprehensive as to the provocation of these, however an initial assessment ruled out significant nerve root or discogenic involvement as this point, but anatomical abnormalities in the alignment of the vertebrae were noted; significant in this instance or not, some spinous processes protruded more than others. In the absence of other findings or observations, it was suggested that the joint laxity could be a area to consider in the pain element of my injury and as such I researched this.

Hypermobility, prevalent in around 3% of the population, is a condition that can present itself as joint pain, joint laxity and skin changes and is caused by the hyper extensive mechanics of the musckoloskeletal connective tissue (Kumar & Lenert, 2017).
The causes of hypermobility are disputed and under reported, with suggestions of genetics and environmental factors all being considered; gene mutations can be found in up to 10% of those presenting with hypermobility as reported by Kumar and Lenert (2017) with biomechanics and proprioception also thought to be associated with the condition.
Whether hypermobility disrupts posture and/or altered gait, often patients seek treatment because of this and as such hypermobility is then found.
However, although joint mobility is common, the condition of hypermobility is only characterised when pain is present and of those with joint mobility, only 3.3% experience associated pain (making up that 3% of the population) (Kumar & Lenert, 2017).

There is currently a wide catalogue of evidence to suggest the link between hypermobility and sports injuries, as the laxity and flexibility in the ligaments preventing joint sprains (Nathan, Davies and Swaine, 2018), however the more specific link to lower back pain is less researched with a lack of published evidence and I found it difficult to make a link between the two.
I did manage to come across research that may start to associate the prevalence of hypermobility amongst individuals with myofascial pelvic pain and lower back pain.
and although this was a small study conducted on 19 subjects, the results were still significant and food for thought.

Regardless of whether the back pain is the caused in this instance, the general advice for treatment includes a management program of exercises to strengthen areas of pain or weakness to help maintain or increase joint stability (Kumar & Lenert, 2017) and as previously found, treatment for non-specific back pain is also most commonly treated by strengthening exercises, for example glute bridges and clams for glute max. and med., (Gasibat, Simbak and Bin, 2017) and as such, this is the treatment route most likely to result in the most effective outcome, in the absence of a clear evidence of and/or protocol for the treatment of lower back pain with any possible hypermobility involvement.

Interesting fact one: Joint pain is also known as arthralgia which I did not know.
Interesting fact two: Not related to this particular case but while researching hyper mobility I found out a great deal of interesting information, of which could prove useful in my future practice as a sports therapist. I was surprised to learn from a study by Fagevik Olsén Brunnegård, Sjöström, Biörserud and Kjellby-Wendt (2017) that joint pain where present in subjects due to receive weight loss surgery, specifically in the hands, ankles, shoulders and feet was increased after weight loss compared with the subjects who had surgery but did not present with hypermobility.
although weight loss is always advocated, especially in individuals experiencing joint pain as a result of this, this study perhaps indicates the need for patient education into the controlled manor in which weight loss should occur and the expectations of the outcome. Although this study was not primarily researching the effects of weight loss on hypermobility, it is an insight into the possible implications of the effects of weight and ligament laxity on joint mobility and pain.

References – 

Bassett, S. (2015). Bridging the intention-behaviour gap with behaviour change strategies for physiotherapy rehabilitation non-adherence. New Zealand Journal of Physiotherapy, 43(3), 105–111. https://doi.org/10.15619/nzjp/43.3.05

Cheng, J. C., Castelein, R. M., Chu, W. C., Danielsson, A. J., Dobbs, M. B., Grivas, T. B., … Burwell, R. G. (2015). Adolescent idiopathic scoliosis. Nature Reviews Disease Primers. https://doi.org/10.1038/nrdp.2015.30

Fagevik Olsén, M., Brunnegård, S., Sjöström, S., Biörserud, C., & Kjellby-Wendt, G. (2017). Increased joint pain after massive weight loss: is there an association with joint hypermobility? Surgery for Obesity and Related Diseases. https://doi.org/10.1016/j.soard.2017.01.018

Gasibat, Q., & Simbak, N. Bin. (2017). Modified Rehabilitation Exercises to Strengthen the Gluteal Muscles with a Significant Improvement in the Lower Back Pain. 2(1), 20–24. https://doi.org/10.17758/eirai.f0217730

Kumar, B., & Lenert, P. (2017). Joint Hypermobility Syndrome: Recognizing a Commonly Overlooked Cause of Chronic Pain. American Journal of Medicine. https://doi.org/10.1016/j.amjmed.2017.02.013

Nathan, J. A., Davies, K., & Swaine, I. (2018). Hypermobility and sports injury. BMJ Open Sport and Exercise Medicine. https://doi.org/10.1136/bmjsem-2018-000366

Trobisch, P., Suess, O., & Schwab, F. (2010). Die idiopathische skoliose. Deutsches Arzteblatt, 107(49), 875–884. https://doi.org/10.3238/arztebl.2010.0875