Total Hours: 188
External Hours: 50
Clinic Hours: 138

Patient 1: Follow up STM for neck and shoulder stiffness
Research spinal stenosis of lumbar and likelihood of occurring in cervical spine
Quality of life questionnaires

This patient was my regular elderly woman who requests STM of her neck and shoulders and presents with almost completely restricted ROM in bilateral side flexion, extension and bilateral rotation of her neck as well as limited ROM in abduction, internal rotation and flexion in her left shoulder. This patient has seen slight increases in motion over the course of the academic year in which she has sought treatment, however changes have often been minimal on a session by session basis, leaving me feeling unsatisfied with progress. Because the patient feels too uncomfortable lying on the couch and requests only STM while seated, I have had limited options in treatment. I have spent much time going through exercises to increase shoulder and neck ROM, reduce rounded shoulders and improve posture, however I continue to question whether these treatments were helping to make a difference to her throughout her daily life; daily living tasks such as getting her coat on and gardening still remains a challenge to her.
Each session, as ROM has been difficult to measure, with changes minimal I was at a loss as to have to measure progress or treatment effectiveness to offer the patient with hope and positive feedback where possible.
This patient was currently reporting pain as her measure, however over the course of the treatments it seems that both pain and ROM will likely remain an issue and as such continuing to focus on these limitations may not prove beneficial to her wellbeing, emotional and physical as it is reported that chronic pain can effect sleep, cause depression, reduced mobility and fatigue (Hawker, 2017). With this in mind, I sought to find another means of measuring this patient’s progress that did not involve negative pain or limitations in ROM.
As might be the case with this patient, using pain questionnaires such the reliable VAS pain questionnaires (Hawker, Mian, Kendzerska, & French, 2011) may just highlight the fact that there is some degree of constant chronic pain but without putting it into context. It was suggested by the clinic manager that quality of life questionnaires may be a useful tool in measuring session by session changes by other psychosocial means, such as improvements in sleep and or general daily living tasks as well as more subjective physical functional ability in relation to their perception of pain (Beaudart et al., 2018; Picavet & Hoeymans, 2004).

The following is an example of the quality of life questionnaire (MSK-HQ) derived by Oxford University to be published by ‘versus arthritis’ https://www.versusarthritis.org/media/7833/msk-hq-2018.pdf. This is appropriately pitched for my patient as it covers basic living tasks, it is simple to fill in and won’t take up too much time. I will hand to my patient to fill out in their own time, which could provide a more dynamic measure of how treatment has worked/is working without focusing solely on pain, which may always be present, but on how it affects her functional ability.

Patient 2: possible strain of wrist flexor/pronators from trauma, reduced Lt Tx mobility and associated tension in upper traps and rhomboids
Cyclist presenting with shoulder flexion pain and limited ROM after fall.
Initially I started to assess the shoulder but it soon became apparent from flexion movements both resisted and active that the biceps, is initially thought due to the insertion beyond the elbow, was not the primary issue. This highlighted the importance of assessing the joint above and below, as sometimes the presentation of pain isn’t indicative of the source. And although the patient came in for shoulder, as a therapist I should remain more open minded as to the location of the dysfunction or pain.

The following is a brief summary of subject and objective assessment notes:
Cx: Full active and passive ROM
GH Jt: discomfort at end range of Abd., Ext. and Int. Rotation of Lt shoulder but no Px in any movements. All other full active, passive and resist. ROM. Slight Px in full resisted flex end range.

Tx: restricted in Lt rotation, compared with Rt. Px in palpating Lt. upper trapezius and Lt. Rhomboids. Aware of forward shoulder posture and related tension and/or weakness.

Elbow: full active and passive ROM. Px in pronation, supination and wrist flex. All other full active and passive wrist and digit ROM with no Px.

From the pain present in pronation and wrist flexion and the elimination of digit involvement as well as the mechanism of injury (reached out to hold onto a branch while falling off of his mountain bike), I looked to treat a potential strain of the wrist flexors and was confidence in prescribing exercises and stretches to facilitate muscle healing . I knew that strengthening would be an option at this stage due to the patient reporting improvements and no recent signs of inflammation and as there was no differences in outcome from early mobilisations and immobilisation of the wrist found by Clementson, Thomsen, Jørgsholm, Besjakov, & Björkman, (2016), I was assured that this was a more progressive method to more functional outcome post the four week mark to which this research tested.

As I observed asymmetry in thoracic spine rotation by way of the seated rotation test, I used this as an objective marker to measure the effectiveness of treatment, with the aim to regain symmetrical motions where possible. As I have not seen this patient before, it was hard to know whether these restrictions were a result of his trauma, or whether they have been there, asymptomatic for a longer period of time. Regardless of this, stiffness in left rotation was evident and the patient experienced slight pain on palpating Lt rhomboids and trapezius.
I applied the following treatment:
Unilat. PA of Tx 2-4 grade 3 and grade 4. Mobs of costovertebral Jt on Lt side; grade 3 and grade 4. STM of Lt Tx, upper trapezius and rhomboids.

This was well received and I think this was due to the transparency of the treatment outcome. I was really pleased to have been able to show the patient the value of the mobilisations as he was pleasantly surprised by the significant difference in his thoracic rotation on the left side.

Because I was treating two different dysfunctions; possible strain of wrist flexors and posture of shoulders and upper body, I forgot to incorporate an objective measure for the wrist injury, the main reason for this patient’s visit. I would usually ask the patient to perform a grip strength test to compare before and after intervention, however as I did not do this, if the patient returns for a follow up assessment, I will use his reports of pain to measure progress, although this is not always the most accurate means. Ordinarily I would include an objective outcome measure for each injury but as there were two elements to this treatment, unfortunately on this occasion I missed this step.

References –

Beaudart, C., Biver, E., Bruyère, O., Cooper, C., Al-Daghri, N., Reginster, J. Y., & Rizzoli, R. (2018). Quality of life assessment in musculo-skeletal health. Aging Clinical and Experimental Research. https://doi.org/10.1007/s40520-017-0794-8

Clementson, M., Thomsen, N., Jørgsholm, P., Besjakov, J., & Björkman, A. (2016). Is early mobilisation better than immobilisation in the treatment of wrist sprains? Journal of Plastic Surgery and Hand Surgery. https://doi.org/10.3109/2000656X.2015.1137925

Hawker, G. A. (2017). The assessment of musculoskeletal pain. Clinical and Experimental Rheumatology. 35(5) S8-S12

Hawker, G. A., Mian, S., Kendzerska, T., & French, M. (2011). Measures of adult pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF. Arthritis Care and Research, 63(SUPPL. 11), 240–252. https://doi.org/10.1002/acr.20543

Picavet, H. S. J., & Hoeymans, N. (2004). Health related quality of life in multiple musculoskeletal diseases: SF-36 and EQ-5D in the DMC3 study. Annals of the Rheumatic Diseases. https://doi.org/10.1136/ard.2003.010769