External Placement Thursday 12th December 2019 – 4 hours (09:00-13:00): 160.5 total

Running total of hours: 160.5

The first four hours of this session was spent treating patients and for me, this was my final opportunity to deliver effective treatment to two returning patients of whom I have watched progress throughout my 50 hours of placement at the Osteopathy clinic.

Patient 1 – Hockey player groin strain – this patient was a regular at the clinic for maintenance of his non-specific lower back pain, however in this particular appointment, he presented with groin pain, which although he could not remember any associated trauma, is likely down to an acute tear of the adductors during a hockey training session.
This has not stopped him playing, however is had been causing him significant discomfort over the past two weeks.
The aims of this session, as well as the usual requested STM and soft tissue mobilisations and lumbar spine joint mobilisations, were to start introducing strengthening of the adductor muscles in order to help prevent further injury.
I did wonder whether there was any research that may be suggestive of a connection between lower back disability and/or pain and adductor injury.
It is commonly reported that muscular imbalances, such as reduced adductor to abductor strength and weaknesses in the hip flexors are a major risk factor for hip or groin injuries (Quinn, 2014). Although back pain is not specifically mentioned, it could be either associated with, or an influencing factor in the development of hip injury, as delayed activation of the transverse abdominus and core weakness is reported as a risk factor with core muscles working as antagonists to the spinal muscles and as assisting global stabilisers of the body (Quinn, 2014).
Because a risk factor for adductor injury can be weaknesses in core and strength imbalances, this may indicate that the treatment that we have been providing this patient over the course of the past 3 sessions have not adequately addressed the strength component of his conditioning. Adherence has always been a factor with this individual; he has two young children, a busy lifestyle and self-reports his lack of motivation to comply with rehabilitation and his reliance in passive modalities.
I am very careful to make sure that the patients are aware of the importance of rehabilitation and commitment to rehabilitation programs and that in order to fully experience long term adaptations and benefits, they must follow their prescribed program.

With regards to return to play for adductor strain, this type of rehabilitation was beyond the capacity of the session; the exercise element is lacking in this clinic with the absence of a gym equipment or space and the osteopaths focus predominantly on passive management and offer only limited exercise based rehabilitation for the patient to take home.
If I were in my own clinic environment, I would look to incorporate evidence based sessions as well as prescribing a program for this patient to take home. Although this patient was given some ideas of one of two exercises, they were not demonstrated or written down.
I would have tried to spend a significant portion of the session providing the patient with a solid understanding of the importance of strengthening and in order to help motivate and empower him to commit to it, I would make sure that he knew exactly what exercises, how many and how often to do them.
The patient’s ability to perform a program would also serve as a good marker for progression which the patient will be able to observe.
This stage of adductor strain would require more focus on proprioception and functional movements and I would look to incorporate the multimodal treatment program as recommended by Weir et al. (2011) and introduce core stability and eccentric adductor strengthening as recommended by Hölmich, Larsen, Krogsgaard and Gluud (2010), a study focusing on football specific adductor strains; a sport related closely to hockey with regards to turning and cutting movements as well as the need for strong core and lower back strength.
As reported in Hölmich et al. (2010) and later in Belhaj, Meftah, Mahir, Lmidmani and Elfatimi (2016) 5-18% of injuries per year are groin related. With a significant 10% of all groin injuries being groin strains (Belhaj et al., 2016) and 72% of those athletes not returning to play due to their injury, more emphasis may be needed on the prevention of these injuries, rather than relying on post injury treatment alone.
A study by Belhaj et al., (2016) reported a major risk factor for groin injuries as more dominance in abductor muscle strength compared with adductors and as such a program focusing mainly on strengthening this muscle group would be beneficial, in particular, eccentric exercises (Hölmich et al., 2010). The study by Hölmich et al. (1999) derived an effective method of rehabilitation that also involved addressing the other key risk factors for injury; core stability training, lower back strengthening and proprioception training for balance and coordination; this method reportedly increased return to play to 80% (Hölmich et al., 1999).
I would therefore look to incorporate simple exercises initially to help improve core strength, balance and proprioception such instability boards for 5mins, adductor strengthening such as side lying hip adductions (5reps10sets) as recommended in the early program by Hölmich et al. (1999) which has been recently supported by Belhaj et al. (2016) and by Hölmich et al. (2010).

As groin injuries, in particular groin strains, are commonly reported as a major cause of time lost in sport, it has been recommended by Weir et al. (2011) that in order to reduce the time taken for return to play, a more multimodal approach or agility drills working at 30% intensity, gradually increasing this when pain free could be more effective than the earlier derived core stability and adductor program by Hölmich et al. (1999).
Agility drills such as ladder exercises can be incorporated in hockey sessions and it may be useful to advise and educate patients on the importance of these exercises in reducing future groin injuries or rate of reoccurrence.

It is worth considering that in order to clinically measure adductor and abductor imbalances, an isokinetic dynamometer is reportedly a reliable tool and is recommended for lower limb injuries (Belhaj et al., 2016). However, this clinic did not have access to such equipment, however, so in any future occasions, manual muscle testing would suffice (this means was also reportedly used in muscle testing of the lower limb).

Patient 2 – Soft Tissue Massage and mobilisation with manipulations performed by Katarina.
This was another opportunity to practice my techniques within a clinical setting. I am feeling much more confident each time that I am able to perform manual techniques on patients and am able to better understand that mechanism behind these techniques and therefore facilitate and coordinate each movement more efficiently. Even more so, as I have recently suffered from a reoccurrence of acute lower back pain and spasms, therefore I need to be careful not to irritate this.
This patient was morbidly obese and as such, it was particularly important to adopt my best possible technique while performing passive lumbar mobilisations and SI joint mobilisations. At the beginning of my time at Exmoor Osteopathy, I did not naturally get my entire body close enough to the patient in order to effectively handle the patient, but in order to preserve my back, I need to ensure that I got as close to the patient as possible to reduce the force that I needed in order to move him.
With a growing number of obese individuals, reportedly an increase in prevalence by 50% to nearly a third of the world population since 1980 (Chooi, Ding and Magkos, 2019), it is very important for me to maintain great technique and to be mindful of my own posture when delivering treatments.
I was able to ensure that I was efficient but with minimal energy expenditure in the correct posture, something I felt as though I have improved upon over than past sessions.

Patient 3 – Shoulder and neck pain – has recently started playing violin and this has caused extra strain and increased pain in contralateral side. It was suggested that the patient find another means of propping her violin on her neck, as this constant position may be increasing her discomfort.
This patient was otherwise fit and active and was a committed runner. It is important in all cases to take other areas of the body into consideration, rather than just assessing and treating the site of pain or injury as whole.

In this instance, it is important to consider the possibility to altered kinematics in any of the surrounding joints of the neck and shoulder, including the thoracic spine or scapular for example, as the biomechanics here can cause pain or injury lower down the kinetic chain.
As I have previously discussed, the Shoulder Symptom Modification Procedure (Lewis, 2009; Lewis, 2011) is a useful tool in assessing, treating and/or preventing non-specific shoulder pain.
As I am currently revising for my rehabilitation exam, within which has a large focus on exercises for rotator cuff injury, I was really excited to get the opportunity to test this procedure on a live patient and to experience this on an individual and real case.
The first part of the session involved soft tissue therapy, mobilisations and manipulations as part of an ongoing treatment plan for the patient. I was able to devote a portion of end of the session to go through the Shoulder Symptom Modification Procedure (SSMP) by Lewis (2009). After educating the patient about their shoulder position and going through the first stage of the SSMP (Lewis, 2009) by asking her to place two fingers on her sternum and pushing them out with her chest, she was able to visually and physically experience the mechanism of the posterior back muscles in relation to shoulder posture. This did have an impact on her pain, but was not absolute in eliminating her symptoms, so I continued further through the procedure to scapular position, which I was able to measure and modify. In the exercises that she had been doing between the previous treatments, scapular motions may have potentially had an impact on their effectiveness,
From reflecting on this session, I am aware that I looked at the whole posterior shoulder movements as a bilateral motion, opposed to unilateral asymmetry, which is more often than not more significant for shoulder pathology and unilateral pain than general posture pain.
Regardless of not assessing each individual scapular, when I manually mobilised the scapular’s on this patient and asked her to perform a push up while quadruped, she reported change in sensation and ease of motion and was more conscious of maintaining the correct posture while performing the exercises, as well as understanding the need to strengthen the muscles that help to retract and depress the scapular. If I were to see this patient again, I would reassess to identify any asymmetry that may be associated with any pain in her present condition. In future I will look at the kinematics of the shoulder both bilaterally and unilaterally to eliminate any muscle dominance or weakness in both or either side of the lower back and shoulders.

Scapular dyskinesis is the winging or altered rhythm of movement of the scapular and can be diagnosed when there is early elevation or protraction in either one or both of the scapulars during movements such as shoulder flexion or abduction and/or winging, whereby the scapular is posteriorly moved from the posterior thorax from the medial border and inferior angle of the scapular (McClure, Tate, Kareha, Irwin and Zlupko, 2009).
Although this patient was slim and any movements of the shoulder and thoracic muscles were easily observed, I have found it incredibly challenging to observe this in many of the other patients I have treated because of the surrounding soft tissue and musculature, an issue also highlighted in McClure et al., (2009). However a more specific clinical test to identify this arrhythmia or winging more easily, known as the scapular dyskinesis test derived by McClure et al. (2009), may prove useful for me in future assessments.
This simple method involves five repetitions of flexion with weighted dumbbells and five repetitions of abduction with weighted dumbbells and hand position with thumbs up and elbows straight. The weight is determined dependent on body weight with subjects above 68.1kg using 2.3kg and those under using 1.4kg weights.
The patient would need to have clothing removed for their scapular rhythm and winging to be clinically observed. According to the aforementioned study, observation should prove reliable enough to identify any dysfunction and accompanied by the SSMP by Lewis (2009), advocating the elimination of symptoms process, I would hope to be able to adjust any possible dyskinesia by way of manual therapy such as physically mobilisation the scapular to the correct position, taping and other means of passive realignment or by way of strengthening and stretching the associated musculature.
For winging, strengthening the serratus anterior would help to drawn the scapular anteriorly back towards the thorax and in order to reduce early elevation and protraction during movements by increasing the activation and/or strength in the lower and middle trapezius and rhomboid muscles to aid in retraction and depression.

I did not have enough time in this session to consider the use of postural elastic therapeutic taping (ETT), which was unfortunate as not only do I think this would have helped to facilitate the completion of any exercises conducted in the session and at home by way of manual postural alignment and neuromuscular stimulation (Han et al., 2015; Harput, Guney, Toprak, Colakoglu and Baltaci, 2017; Lewis, 2009; Shih et al., 2017), it would have given me the opportunity to gauge whether I found this useful and effective from a clinical perspective on a real case and practice the procedure.
In any aspect of taping for shoulder pain, there is reportedly little supporting evidence of its effectiveness (Mostafavifar, Wertz and Borchers, 2013) and the suggested likelihood of the nature of placebo being a possible explanation for any findings (Poon et al., 2015) limits clinician’s ability to use this treatment with confidence. From the evidence that is available, Harput et al. (2017) found that in asymptomatic subjects who may be at risk of shoulder injury, overhead athletes for example, ETT taping was recommended for prevention of sub acromial impingement syndrome, a condition associated with shoulder position for which both Shih et al. (2017) and Han et al. (2015) found ETT effective. With effective application of this method with tape at 30-40% stretch, Han et al. (2015) was able to rule out the effects of placebo by way of conducting a single blind study, but with the effects suggested to be attributed to neurophysiology as opposed to mechanical adaptions.

References –

Belhaj, K., Meftah, S., Mahir, L., Lmidmani, F., & Elfatimi, A. (2016). Isokinetic imbalance of adductor–abductor hip muscles in professional soccer players with chronic adductor-related groin pain. European Journal of Sport Science. https://doi.org/10.1080/17461391.2016.1164248

Chooi, Y. C., Ding, C., & Magkos, F. (2019). The epidemiology of obesity. Metabolism: Clinical and Experimental. https://doi.org/10.1016/j.metabol.2018.09.005

Han, J. T., Lee, J. H., & Yoon, C. H. (2015). The mechanical effect of kinesiology tape on rounded shoulder posture in seated male workers: A single-blinded randomized controlled pilot study. Physiotherapy Theory and P

Harput, G., Guney, H., Toprak, U., Colakoglu, F., & Baltaci, G. (2017). Acute effects of scapular Kinesio Taping® on shoulder rotator strength, ROM and acromiohumeral distance in asymptomatic overhead athletes. Journal of Sports Medicine and Physical Fitness. https://doi.org/10.23736/S0022-4707.16.06583-X

Hölmich, P., Larsen, K., Krogsgaard, K., & Gluud, C. (2010). Exercise program for prevention of groin pain in football players: A cluster-randomized trial. Scandinavian Journal of Medicine and Science in Sports, 20(6), 814–821. https://doi.org/10.1111/j.1600-0838.2009.00998.x

Hölmich, Per, Uhrskou, P., Ulnits, L., Kanstrup, I. L., Bachmann Nielsen, M., Bjerg, A. M., & Krogsgaarda, K. (1999). Effectiveness of active physical training as treatment for long-standing adductor-related groin pain in athletes: Randomised trial. Lancet. https://doi.org/10.1016/S0140-6736(98)03340-6

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, 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

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

McClure, P., Tate, A. R., Kareha, S., Irwin, D., & Zlupko, E. (2009). A clinical method for identifying scapular dyskinesis, part 1: Reliability. Journal of Athletic Training. https://doi.org/10.4085/1062-6050-44.2.160

Mostafavifar, M., Wertz, J., & Borchers, J. (2013). A systematic review of the effectiveness of kinesio taping for musculoskeletal injury. Physician and Sportsmedicine. https://doi.org/10.3810/psm.2012.11.1986

Poon, K. Y., Li, S. M., Roper, M. G., Wong, M. K. M., Wong, O., & Cheung, R. T. H. (2015). Kinesiology tape does not facilitate muscle performance: A deceptive controlled trial. Manual Therapy. https://doi.org/10.1016/j.math.2014.07.013

Shih, H. S., Chen, S. S., Cheng, S. C., Chang, H. W., Wu, P. R., Yang, J. S., … Tsou, J. Y. (2017). Effects of Kinesio taping and exercise on forward head posture. Journal of Back and Musculoskeletal Rehabilitation. https://doi.org/10.3233/BMR-150346

Weir, A., Jansen, J. A. C. G., van de Port, I. G. L., Van de Sande, H. B. A., Tol, J. L., & Backx, F. J. G. (2011). Manual or exercise therapy for long-standing adductor-related groin pain: A randomised controlled clinical trial. Manual Therapy. https://doi.org/10.1016/j.math.2010.09.001

 

 

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