Running total: 151.5

Patient 1 and Patient 2 – both my first and second patients in this session were follow ups from previous weeks who requested soft tissue treatment; the first usually attends the clinic weekly and the second has recently started returning on a fortnightly basis.
These sessions were requests and neither patient had considered the potential for further investigations or alternative treatment options and as such I fulfilled their requests and provided them with their treatment.
It was brought to my attention that the patient had a comprehensive injury history to his hip, which was of interest to me and as such I used the time that I was administering STM to ask about his condition as well ask about his experiences.
The patient had a history of a labral tear and femoral acetabular impingement (FAI) and underwent a hip arthroscopy two years prior to this session.
I had little prior knowledge of acetabulum labral tears or FAI and the management of these within a clinical setting, but did some follow up research to better understand this patient’s current rationale behind his ongoing and recurrent visits to the clinic.
Interestingly, acetabular tears are common and are often seen in young and physically active individuals (Smith, Panchal, Ruberte Thiele and Sekiya, 2011). Due to the recurring nature of this patient’s discomfort and how he is unable to manage this through home rehabilitation, I had wondered whether this was typical in patients with previous labral injuries. Specifically, I was intrigued as to how much surgery and/or a labral tear effected hip stability. In a study by Smith et al. (2011) which set out to test whether labral tears significantly affected hip stability, it was found that although removal of at 2cm of the acetabulum by means of a labrectomy removal results in instability, the presence of labral tears or up to 1cm removal of acetabulum had in fact no effect. This research was only done of a cadaver, however so it does not take into account surrounding muscle activation in the aid of movements and stability and the effects of surgical intervention on these structures.
In this particular case, the patient had an arthroscopy, which is reported as being successful in treating patients who experience pain and reduced function after FAI surgery (Philippon, Briggs, Yen, & Kuppersmith, 2009; Sardana et al., 2015). The labral tear may have been debrided in the same procedure but unfortunately, I did not ask the patient about the full extent of the surgical treatment he had undergone because I did not have enough knowledge at this point to fully understand.
The arthroscopy would have been initially performed to treat the impingement but any other pathology would have been assessed and treated where possible, in the same procedure.
Interestingly, out of a study group of 7,351 subjects who attended a follow up appointment two years post hip arthroscopy, 11.7% ended up needing total hip arthroplasty (THA), of which 3% were under 40 (Schairer et al., 2016). It was also found that on average a THA was performed 16 months post arthroscopy (Philippon et al. 2009).

According to Philippon et al. (2009), restoration of excellent functional ability can be influenced by the patient’s participation in rehabilitation and in this study it is simply recommended that the course of treatment immediately post-surgery ensures the restoration of passive before active movements and then strength training with additional hip pendulum exercises. I do not know if the patient followed a prescribed exercise plan after his surgery but I will discuss this with him during his next appointment as I would be interested to know whether this has impacted on his functional ability now. I have understood from this research the need to be prepared for the prospect of a THA but also I have gathered confidence that a successful outcome is viable and as such I will continue to treat this patient as requested in the hope that a more long term management plan is created or improvements are made.
I learnt from this particular research that in order to determine FAI, the following tests are recommended;
FABERS, Quadrant Test, ROM, specifically flexion, adduction and abduction and both internal and external rotation.

As I wrote about earlier in my reflections, I struggle with time keeping. Unfortunately, I ran out of time at the end of this session and found it difficult to end the conversation with this patient meaning that the session overran into the next.
I believe that much of this patient’s need stems from a psychosocial perspective and that he really would like some company, something he even mentioned earlier in the session.
I am not very comfortable with cutting people short when they are engaging in a conversation with me, especially as I feel like I was providing him with a listening ear for his potential anxieties. However, I know that in order to fulfil all appointments today and maintain structure and professionalism, I needed to wrap up the session. From reflecting on this, although there are circumstances whereby a patient will continue to talk regardless of my influence, I feel that in order to end the session on this, I should look to wind down the conversation earlier.
I do feel as though this has improved over the past 3 months, but I am still looking to consider other strategies, such as the use of body language and physically bringing the conversation or session to a close by slowly tidying up from the session and making my way to the reception.
After having spent many hours observing and working alongside Kat Stenner at the osteopathy clinic, I have been able to pick up on how she addresses this issue and admittedly, sometimes this scenario is unavoidable and in these cases, the patient’s wellbeing really is more important than a schedule and providing an listening ear is more important, however similar strategies such as tidying up and discussing payment starts to effectively channel the conversation to a close but in a polite and subtle manner.

Patient 3 – Follow up for thoracic spine mobility and shoulder pain
This was the third appointment for this patient in the clinic, with this session being his follow up. Unfortunately, as my previous patient was late leaving on this occasion, I had very little time to pre-read this patients notes and thought I could do this while engaging in a follow up conversation, but this was not the case and instead, I found myself having to apologise for not remembering much of this case. I was so sure that my poor memory of his injury and rehabilitation and lack of pre reading was noticed by him and I felt as though I wasn’t giving him the best possible treatment at that time.
I feel as though it is a more personable experience when you are greeted by your practitioner who has obviously either remembered you or have done some pre reading on your case. In my future practice, I will make a point to thoroughly read through previous notes, even if this makes me even later in starting the next appointment. I did apologise to the patient for my forgetfulness and explained about the previous session overrunning but took responsibility for my lack of preparation and as I was able to recall his information eventually, the patient was understanding and we made a joke of it.

As mentioned before, this is the third time that I have seen this patient and although progress has been made, it is slow and the symptoms have returned each time.
I was very excited to be able to incorporate some theory that I learnt from lectures in recent weeks regarding the shoulder as this was most relevant in this case. I feel as though I wish I had been able to apply this knowledge much earlier on in this patient’s rehabilitation, as he may not have needed to return by now because not only would we have treated symptoms but we would have looked at his whole kinetic chain and therefore multidimensions of shoulder and thoracic movements, assessing, diagnosis and subsequently correcting any possible underlying causes of symptoms.

For example, scapular stabilisations, thoracic curvature and humeral head procedure as outlined in the Shoulder Symptom Modification procedure (Lewis, Wright and Green, 2005; Lewis et al., 2009; Lewis, 2011). Using this model I first assessed him thoracic spine, which showed good clinical outcomes and I was able to observe full ROM with no pain or restrictions; this may have been due to his excellent adherence to the rehabilitation for increasing his thoracic mobility over his previous sessions. Instead, I looked at his scapulars only to find them both upwardly rotated which was indicative of weakened serratus anterior and lower traps and/or over active upper traps.
I advised the patient to perform scapular stabilisation exercises against the wall and educated the patient on the best position and how to obtain this. I was confident that the patient was aware of how to correct his scapular positions and our intended outcome and explained the need for these simple closed kinetic chain exercises in order to build endurance of the stabilisation muscles of the scapular before progressing the exercises to more dynamic, isotonic open kinetic exercises which may alter the scapular kinematics; until the patient can maintain stabilisation by way of increased muscular endurance in the right postural muscles such as the lower and middle traps and serratus anterior, more functional motions will be difficult to perform and technique may be compromised.

I suggested that after a short program of wall stabilisation exercises, the patient could progress to doing them on floor and incorporating push ups which a maintained technique. This would provide the patient with a more dynamic approach to his rehabilitation, as he is already an active individual with reasonable levels of fitness.

Patient 4 – Scoliosis follow up
I was really looking forward to seeing this patient again, as I had conducted a great deal of research surrounding this condition. In the previous session I videoed his forward flexion and observed the curvature in this movement, which really fascinated me. I started the session by performing a follow up subjective and objective assessment which was all positive, however when asked to perform the single leg stance, it became apparent that the patient had made no progress in stability or in developing symmetrical strength in his stabilising muscles in his back; he was unable to maintain a steady stance and was significantly wobbly throughout the movement. When I asked the patient about the exercises given to him to improve this, he informed me that he did not do them. Fortunately we did perform a clinical objective measure of the single leg stance and so I was able to explain to the patient, through observation, what the outcomes of his rehabilitation was and as it was obvious to see no improvements in this exercise, I was able to help him to understand the implications in his low adherence. Although I was happy that the patient was performing all other exercises, it was this particular one that would have enabled progression through to more functional, dynamic exercises. However, as the patient was still unable to perform the single leg stance in a stable manner, we could not progress.
I wanted to ensure that the patient was happy with his program, to which he responded positively and merely that he had forgotten to include this particular exercise.
From having researched this condition and from having communicated what I had learnt to the patient, I feel more confident that the he had acquired more knowledge and possibly empowered him a little giving him more hope as to his possibilities to live in less pain.
In future I will make sure that we double check that the patient has a good exercise plan to refer to and to review before they leave to clinic to ensure that they know to complete all exercises.

Because he had progressed well in his thoracic mobility exercises, I did add another exercise to enhance this further but to also look to improve his core stability. This was the bird dog. I used this time to practice coaching this technique and as he was not fully able to perform it at first, I needed to adjust the routine; his coordination was the limiting factor instead of his core strength, so instead of the usual opposite leg and arm at the same time, I regressed this to one movement at a time.

I am looking forward to the next session, where we will look to progress his exercises further and hopefully observe improvements.

Extra time between patients – I used this time to physically perform all of the exercises that I had so far prescribed in my clinic session. Unfortunately I did not have any other students to discuss and practice these with as they were all busy with clients, but I was able to use all of the equipment and have a go. I find explaining exercises very difficult as I usually have only read about them in theory and have no actually tried them out myself. Sometimes manoeuvring myself around the equipment, especially the gym balls is quite a challenge, so demonstrating this to patients seems slightly more difficult than it should be. By taking the time to use the equipment, I am also able to fully appreciate how difficult some exercises can be to master and therefore I can start with more simpler ones for some patients; some are much harder than they look, such as a bilateral hamstring curl, especially for myself who is not used to this type of demand!

References –

Lewis, J. S. (2009). Rotator cuff tendinopathy/subacromial impingement syndrome: Is it time for a new method of assessment? British Journal of Sports Medicine, 43(4), 259–264. https://doi.org/10.1136/bjsm.2008.052183

Lewis, J. S. (2011). Shoulder Symptom Modification Procedure ( SSMP ) V2 Date : Symptomatic movement or posture 1 : Symptomatic movement or posture 2 : (1), 2011.

Lewis, Jeremy S., Wright, C., & Green, A. (2005). Subacromial impingement syndrome: The effect of changing posture on shoulder range of movement. Journal of Orthopaedic and Sports Physical Therapy. https://doi.org/10.2519/jospt.2005.35.2.72

Philippon, M. J., Briggs, K. K., Yen, Y. M., & Kuppersmith, D. A. (2009). Outcomes following hip arthroscopy for femoroacetabular impingement with associated chondrolabral dysfunction: Minimum two-year follow-up. Journal of Bone and Joint Surgery – Series B, 91(1), 16–23. https://doi.org/10.1302/0301-620X.91B1.21329

Sardana, V., Philippon, M. J., De Sa, D., Bedi, A., Ye, L., Simunovic, N., & Ayeni, O. R. (2015). Revision Hip Arthroscopy Indications and Outcomes: A Systematic Review. Arthroscopy – Journal of Arthroscopic and Related Surgery. https://doi.org/10.1016/j.arthro.2015.03.039

Smith, M. V., Panchal, H. B., Ruberte Thiele, R. A., & Sekiya, J. K. (2011). Effect of Acetabular Labrum Tears on Hip Stability and Labral Strain in a Joint Compression Model. American Journal of Sports Medicine. https://doi.org/10.1177/0363546511400981