Running Total of Hours: 186
External Hours: 50

In my attempts to incorporate elements of the reflective model cycle by Gibbs et al. (1988), I have found it quite difficult to use this exact template in this session because of the nature of our practice; this week lacked in any new treatments that I would fully benefit from detailed reflective analysis. I appreciate the value of a structured reflective writing and will continue to the model for reflections however, this week may not fully benefit from this means of reflection.

Patient 1 – My first patient did not arrive, so I took this opportunity once again to partner up with another student who was conducting an assessment of the lumbar spine in a patient with non-specific lower back pain. Earlier in my clinical experience, I saw many patients who presented with lower back pain and I started to feel more confident in this assessment and in managing this condition, however I have not had the opportunity to practice recently and feel as though this is an area that I need to redevelop.
I was able to work through a thorough assessment by means of range of motion, including functional combined motions and muscular control, all of which seemed as expected and bilaterally symmetrical. From my previous experiences with patients presenting with lower back pain, a generalized approach, such as core stability exercises has been most effective (Chang, Lin, & Lai, 2015).
I also found that from previous treatments, posteroanterior mobilisations provided immediate pain relief and increased ROM, as supported and recommended by (Shah & Kage, 2016; Shum, Tsung, & Lee, 2013).
Because of the comprehensive range of exercises, I posted in my reflections from earlier patients, I was able to refer to a range of options for this patient to use and I felt confident in their effectiveness. I was therefore excited to see how they would be received.
I found that by showing the patient visual guides by way of photos, before demonstrating the exercises myself, the patient was far more understanding of what was expected of them. In this instance I used my previous reflections as a reference for the patient, however in the future I will look to build a portfolio of exercises in a folder with handout sheets that I can be readily available for cases such as these.
As well as the aforementioned research on general strengthening of the glutes and erector spinae, I recently came across a study on the effectiveness of stretching the low back to help improve pain and mobility in lower back pain patients (Fernandez & A D, 2015). Because the research is increasing more focused on strengthening, I tend to leave out any stretching within prescriptions of intervention. In my research on forward shoulder posture, I have found that a combination of strengthening and stretching is the most effective means of reducing rounded shoulders and pain and improving function and range of motion but means of treating the two muscle groups (pectoralis minor and scapular muscles) to facilitate one another in their influence on posture; strengthen the scapular and thoracic region muscles but lengthen the pectoralis minor, as this also attaches to the scapular and can help allow for any kinematic alterations through exercise).
By way of a similar mechanism, but strengthening the lateral hip abductor (gluteus med., TFL) and stretching the quadratus lumborum, rectus femoris and/or hamstrings, which ever is objectively found to present with any excessive tightness, ROM of the lower back and hip may be improved.
It is important to establish which muscles are weak and which are shortened, or lengthened depending on the dysfunction and to work with this, so a thorough objective assessment is paramount in ensuring the correct program which may include the hamstrings and iliopsoas (Fernandez et al., 2015) and quadratus lumborum, erecter spinae, and TFL (Dhargalkar, Kulkarni, & Ghodey, 2017).
In future I will look to incorporate an element of both of these components into a program as a way of a more multidimensional approach.

Fortunately by the end of the session, the patient and I came up with a stretch that seemed to target the affected area. The only way to know whether this could be an effective intervention is by advising her to do this at home on a daily basis and reiterate the importance of a prolonged stretch; I always advise greater than 25 seconds as a minimal, 30 seconds gold standard. From my research, I learned of the effectiveness of passive stretching by way of muscle energy techniques (Dhargalkar, Kulkarni and Ghodey, 2017) that I could administer, should the patient return and feel as though her active stretching was ineffective. This was useful to know, as TFL stretching can be difficult at home, so I would consider incorporating an element of stretching in the allotted treatment session, not only to allow the patient to understand the benefits of stretching by way of seeing for themselves any objective lengthening or experiencing any pain relief benefits but also to facilitate their home program and ‘start them off’. But encouraging progress early on, they may feel inspired to continue their program at home.
I also suggested the use of muscle energy technique stretching if which I had not previously

Patient 2 – Previous history of impingement with new presentation of pain in thoracic spine and scapular stabilising muscles
Descriptions – This patient was a youth aged 15 and from my previous experiences of treating younger individuals, I have found that I tend to address most questions to and converse with their parent in the room, instead of the patient. I have been aware that I did this and as such I was prepared to engage fully and directly with the patient and involve the parent only when absolutely necessary and on request of the patient.
In previous appointments with young patients, I found that speaking in a simple and clear manner was especially effective to ensure that they fully understand the elements of their treatment and I even developed this further by going into a little more detail, although simply put, into our methods of treatments as she had expressed a particular interest in what I was doing.
Feelings – Although I felt confident delivering relevant tests and performing a comprehensive assessment, I still felt anxious due to the age of the patient. I still do not feel entirely confident when treating young patients due to the complexity of their growth patterns and the implications of an injury on their future in sport. In order to ensure that I was doing the very best for my patient, I conducted a thorough subjective and objective assessment before consulting the clinic manager to confirm my findings and to discuss treatment options. I felt better after gaining reassurance from the clinic manager as we had come to a similar impression of injury.
Evaluation – Overall I felt happy with my delivery of this session, although I feel as though I should be able to follow through an entire treatment at this stage in the academic year without additional advice from the clinic staff, especially with a patient displaying symptoms I regularly treat, however I am sure that the more patients I see, the more my confidence will grow. I am also aware that after this course, I may not have the opportunity to ask senior therapists’ advice and so I should fully utilise the resources while they are available to maximise my learning opportunities.
Conclusion – Despite my initial anxiety around treating a young patient, I was able to identify their injury with confidence, but also proceed with caution regarding their overall rehabilitation plan and load. Although limited, my knowledge of the differences in younger patients’ physiology was enough to identity the need to be aware and with that, I became heightened to the importance of patient education and the need to identify any ongoing risk factors that may be contributing to her pain.
Action plan – In order to gain a little more confidence in treating young people, I will take time away from the clinic to research the general physiological differences in the younger population and common injuries they may be more likely susceptible to. This will help to make me more aware of the rationale behind some treatments and the precautions that I will need to take in treatments and in prescribing rehabilitation plans.
I was aware that this 15 year old was training excessive amounts throughout the week, but before I could offer advice, I need to obtain more knowledge surrounding the effects of overtraining and periodisation of exercise programs, as well as recommended guidelines on training load.

The above was my first attempt at a structured model of reflective writing and I found it a really effective way to condense my writing into relevant sections of information and where I may have forgotten to add an action plan, this is a good reinforcement of the need for further and continued development. Although this was simple, due to the simple nature of this case, it was a good chance for me to get used to this way of reflective practice.

Patient 3 –
This was a STM for a keen runner who is currently running recreationally but who has in the past run marathons and competitions. There was no injury in this case, or the need for a detailed assessment but nonetheless I carried out a basic relevant assessment to ensure good health and wellbeing of this patient and to rule out the need for further treatment. This patient has no reports of injury and pain and simply praises the benefits felt from STM massage and as such I administered STM of various means to her hamstrings, quadriceps and calf muscles, maintaining professionalism and efficiency throughout.
The patient received the treatment well and was satisfied with her treatment.

References – 

Chang, W. D., Lin, H. Y., & Lai, P. T. (2015). Core strength training for patients with chronic low back pain. Journal of Physical Therapy Science, 27(3), 619–622. https://doi.org/10.1589/jpts.27.619

Dhargalkar, P., Kulkarni, A., & Ghodey, S. (2017). Added effect of muscle energy technique for improving functional ability in patients with chronic nonspecific low back pain. International Journal of Physiotherapy and Research. https://doi.org/10.16965/ijpr.2017.144

Fernandez, E. L., & A D, G. (2015). Efficacy of active stretching over passive stretching on the functional outcome among patients with mechanical low back pain. International Journal of Physiotherapy and Research. https://doi.org/10.16965/ijpr.2014.702

Gibbs, G. (1988). Learning by Doing: A guide to teaching and learning methods. London: Further Education Unit.

Shah, S. G., & Kage, V. (2016). Effect of seven sessions of posterior-to-anterior spinal mobilisation versus prone press-ups in non-specific low back pain-randomized clinical trial. Journal of Clinical and Diagnostic Research, 10(3), 10–13. https://doi.org/10.7860/JCDR/2016/15898.7485