Running total of hours – 179.5
Patient 1 –
The rehabilitation sessions for this patient had focused primarily on thoracic mobility and exercises to facilitate full pain free ROM, advancing to strengthening with the end goal of increasing strength and shoulder proprioception to prevent future injury. Good progress was made at the beginning of the treatment sessions, with good patient satisfaction and noticeable improvements in clinical markers such as pain and ROM. As symptoms did not completely subside, I looked into identifying other possible factors that may have been causing the pain, to which I found potential asymmetry in scapular motion and possible weakness in the patient’s serratus anterior muscles bilaterally and shortened pectoralis muscles. Since incorporating the scapular stabilisation exercises, the patient has further reported improvements in his symptoms and a greater awareness of his posture. The exercises that I gave the patient were appropriate, however I did need to review his technique during this session as he was still unsure as to the positioning of his body. He did not perform the push ups against the wall, he went straight to the floor as he felt that this would have challenged his proprioception more. This was advised by myself, however I need to make it clear that the patient is aware of the need to practice the correct muscle firing patterns and scapular alignment in simpler exercises before progressing exercises too soon, as this would risk under activating of the right muscles needed for correct movement.
From revising earlier reflections on my sessions with this patient, in particular a session in November 3rd 2019, I noticed that progress was excellent at the beginning of treatment and the patient reported much less pain and more range of motion from the treatments and exercise prescription at the time, however it was my aim from that point to reduce this patient’s dependence on the clinic. After a discussion with this patient in this most recent session, I was reassured that the patient now had a much better understanding of the reasons for the particular exercises and now has the knowledge in how to progress these activities himself in a gym or home setting. His reliance on the clinic has also gradually decreased with sessions occurring monthly as opposed to fortnightly. The thoracic spine exercises prescribed in the session dated back to November were incorporated into this patient’s rehabilitation early on, to which he reported good self-adherence, however clinical measures did not seem to indicate any further increases in mobility, nor a continuing deficit. Since progressing assessment and using the symptom modification procedure to add another dimension to this patient’s treatment, focusing more on scapular stabilisation and serratus anterior activation, these exercises were no longer required in such large volumes on a week to week basis. Instead, focusing more on rotator cuff strengthening and scapular stabilisation exercises would be more effective in enhancing this patient’s strength and reducing the risk of further injury. Mobility exercises can be performed regularly as a means of maintenance but do not need to form the basis of rehabilitation as his mobility is, at this stage, excellent.
To further enhance this patient’s rehabilitation, now that he has regained full strength and ROM in his shoulders and good mobility in his thoracic spine, I will look to progress his exercises to incorporate more proprioception and then plyometric work to not only facilitate the strength and pain free range of motion in his everyday tasks and occupational workload, but to enhance his gym abilities and to help reduce the risk of future injuries.
Patient 2 – Recent Tibial Tubercle Osteotomy for Patellofemoral Instability on Rt, presenting with similar symptoms on Lt.
This patient is a young female who has recently had surgery (4/12 ago) on her Rt knee to treat recurring dislocations, which involved the re positioning of the patella by way of completely detaching the tibial tubercle and attached patella insertion, to be relocated medially; shifting the whole quadriceps and patella complex (Caton & Dejour, 2010). This left the patient with a difficult rehabilitation program, from which she sought from the clinic shortly after her surgery. The rehabilitation plan involved strengthening of her core, lower back and lateral hip muscles as well as addressing imbalances in hamstrings, adductors and quadriceps.
The patient had returned to the clinic as she would like to return back to rugby, but due to the instability in her non surgically treated knee (this had also dislocated twice in recent months), she feels apprehensive about playing and also finds it painful to run; reporting a 7 out of 10.
After a thorough assessment, bilateral functional weaknesses in her knees were evident by way of her inability to stabilise her motion during a single leg squat. Bilateral tightness in her hip flexors and quadriceps were also apparent with additional knee valgus and internal rotation of the hip. At first I wondered if this was due to apprehension and fear of re-injury, however from communicating sensitively with this patient, this may not have been the most influencing factor, as she self-reported minimal fear in this particular movement, but in explosive playing movements only.
This patient has experienced reoccurring knee dislocations in both knees, which can be indicative of needing surgical treatment, criteria specifically reported as “objective patellar instability with true dislocation of the patella with or without patella alta and trochlear dysplasia” (Caton & Dejour, 2010 p309). MRI imaging of her right leg confirmed the need for patella repositioning; however she has not yet been referred for imaging of her right leg due to the short term nature and recent onset of the left leg instability. The only clinical symptoms for this leg have been the dislocations.
I found this appointment really challenging because I have not yet experienced knee instability at such a degree and I was concerned that I would cause further damage or potentially risk dislocation. I also find it difficult to fully identify and isolate the muscles that are the weakest and to develop a program most suitable for the needs of an individual. I felt as though I had lost all of my confidence and had to seek advice from the clinic manager, who shared a wide variety of strengthening exercises focusing mostly on quadricep strengthening, which now I have reflected upon the treatment, I can understand the need behind this, due to the potential complications from the surgery and the need to prevent dislocation in the other knee. I should have focused on the location of the injury site and the rationale behind the surgery to have determined the need for quadricep strengthening.
I was, however, confident in identifying hip abductor weaknesses and the need for abduction strengthening exercises to improve hip and knee strength by way of decreasing knee valgus and hip internal rotation. I was able to learn from previous treatments, the value of the bridge exercise with additional resistance bands around the thighs or progressed to around the ankles to activate abductors (Choi et al., 2015) and the clam exercise with resistance bands, again around either the ankle or the thigh (Willcox & Burden, 2013).
This session highlighted an area of confidence and knowledge that I am lacking, however from this, I can better appreciate the importance of keeping it simple and starting with simple exercises and using each individual as an indicative marker as to their readiness for progression. This patient found 5kg of weight on a leg press a 7/10 excursion but was doing 4 sets of 12 and was feeling no additional benefits from this, being unable to progress to bigger weights. Although the weights seem relatively low, considering the patient’s usual workload of rugby and gym sessions, I would be tempted to look to increase this, however as she had such a high exertion for such a low load, I had to approach this differently. Instead, I looked to find ways to reduce the patient’s perceived exertion before progressing weights. By reducing the patient’s reps to 10 and the sets to 3, I gave my patient the goal to reduce effort to as little as 3/10 before increasing the weights on the leg press. This not only gave the patient a goal, as I often miss in my sessions, but it gave us a means to determine how to adjust reps and sets. I advised the patient to further reduce these if no improvements were felt, which may have helped to empowered her to take responsibility for her own routine to some extent.
By using exertion as a measure instead of weights and reps and sets, it offers the patient another dimension to their ability to understand their progression a little better, especially for patients who are not used to gym equipment or have access to equipment than offer weight increments.
This approach to muscular strength also looks to address the neurological responses to muscular activation and the athlete’s perceived ability to perform movements are more closely analysed as opposed to more numerical, objective targets.
References –
Caton, J. H., & Dejour, D. (2010). Tibial tubercle osteotomy in patello-femoral instability and in patellar height abnormality. International Orthopaedics, 34(2 SPECIAL ISSUE), 305–309. https://doi.org/10.1007/s00264-009-0929-4
Choi, S. A., Cynn, H. S., Yi, C. H., Kwon, O. Y., Yoon, T. L., Choi, W. J., & Lee, J. H. (2015). Isometric hip abduction using a Thera-Band alters gluteus maximus muscle activity and the anterior pelvic tilt angle during bridging exercise. Journal of Electromyography and Kinesiology, 25(2), 310–315. https://doi.org/10.1016/j.jelekin.2014.09.005
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