Clinical Experience Monday 2nd March 2020 – 3 hours (16:00-19:00): 195 hours

Total Hours: 195
External Hours: 50
Clinic Hours: 145

Patient 1 – STM of legs; hamstrings, quadriceps and gastrocnemius muscles.
From my previous week of treatments, it was reinforced that communicating to the patient about their daily activities may reveal more about their injury or risk of injury than a subjective assessment itself, as often they talk about things that don’t seem relevant to them at the time of questions and/or they feel more comfortable talking about themselves later in the treatment session.
Although this patient was clear in request for a STM, through conversation, I revealed the need for education on training load as preventative measure.
As I have found in recent treatments, patients have responded well to visual cues through photos and diagrams such as with various different exercise routines. As I found the concept of tendinopathies challenging to grasp, I anticipate it may be difficult for patients to fully understand too, therefore by showing them the table that best taught me, I would be able to give the opportunity to better understand the importance of managing load to reduce the chance of injury (Cook & Purdam, 2009; Lewis, 2009).
An example of a continuum is shown below and although this was derived for the rotator cuff it is still a useful guide to the pathology.

In the past, questions about workload and training schedules did not occur to me until much later in the treatment, however I have come to realise the importance of this and the importance of clear communication with the patient regarding appropriate loading. The patient had informed me that he started to increase his load from January after entering an ironman in July this year, however he also explained that he had never done anything like this before. I did take into account that this patient was in the military and so had a very good basic level of fitness, however this does not mean that he had an appropriately loaded tendon for the increase in running and I explained that even if there are currently no symptoms, that pain isn’t necessarily a good indicated of a tendon pathology as this is accumulative in nature and may not present itself as pain until after the tendon is in the reactive tendinopathy or disrepair phases. I did not want to make my patient apprehensive about training, but I felt that it was very important to make him aware of overload. He did report low level discomfort in his achillies tendon, which I advised he used as an objective measure over the coming training months; reduce load and if the pain is less up to three days after training, then this is a good indication that the load was appropriate. If the patient experiences increase in discomfort, then he knows to reduce his load.

With regards to the massage treatment, I am always vigilant when it comes to ensuring that I am applying the appropriate pressure. Some patients are much more reluctant to say that they would like more or less pressure so I am careful to always ask for feedback throughout and try to maintain a relaxed atmosphere so that they would feel comfortable in saying.
This patient did ask for more pressure at times, but equally felt that at some points, I was applying too much. Although this may seem inconsistent, I was reassured by the fact that I was providing a large area of massage that included some more sensitive areas than others. However, it may be an indication that I need to try to be more aware of which muscles I am targeting and the pressures that they may be able to withstand, for example this patient was a cyclist, a sport in which cause notoriously “tight” quadriceps, so with this in mind, I could have been especially sensitive in this area.

Patient 2 – Once again my patient did not arrive and although this is extremely frustrating for myself as I lose out on the opportunity to gain valuable experience, however I still got to take advantage of the equipment and the knowledge and experience of other students and we took the chance to practice spinal anatomy. Even though this was a first year learning task, it still remains a challenge for me to efficiently palpate and identify the correct spinous processes, especially when the patients have a higher percentage of body fat. When working with live patients, I often spend too much time trying the exact location of any pain or treatment area and sometimes I am not sure. This is not so much of an issue when treatment is concerned as I can treat the symptoms based on patient feedback and my objective assessment, however when writing notes for other therapists to see at follow up appointments, it is important to write in as much accuracy, the location and type of treatment.
For example, if a patient has stiffness in T4 through to T6 and I performed central PA mobilisations in treatment, but did not state the location, in future appointments, therapists may not know the benefit or ineffectiveness of the treatment if they have no information as to previous sessions. Also, if the location of when I performed treatment is inaccurate, then in future assessments, objective information may not present in an expected way.
I do understand the importance of practice and the need for experience in palpating many different spines and those with or without dysfunction/pathology, however I do not always get the chance to do so.
By practicing on another student, I was able to ask for feedback as to how it feels for them for me to prod them and also ask other students to help identify landmarks with me, a luxury that I do not have when working with patients and when I finish this course.

I learned from this practice that counting from C1 through to the distal spine is not the most effective means, but that making relative location associations at varying levels was.
In order to learn a good method of remembering spinous process locations, we brought up a video to guide us, which can be seen in the following link:

Cervical Spine: https://www.youtube.com/watch?v=6azgWYMQfWU&t=135s

C6 disappears when patient extends neck, C7 remains prominent!

Thoracic Spine: https://www.youtube.com/watch?v=3hRFXCgnABE

T7 inline with inferior angle of the scapular

Lumbar Spine: https://www.bing.com/videos/search?q=palpating+spine&&view=detail&mid=D0925B3114E7265DD374D0925B3114E7265DD374&&FORM=VRDGAR&ru=%2Fvideos%2Fsearch%3Fq%3Dpalpating%2520spine%26qs%3Dn%26form%3DQBVR%26sp%3D-1%26pq%3Dpalpating%2520spine%26sc%3D4-15%26sk%3D%26cvid%3D7BCF41200DB24C4394E2DB3D08B4A1DE

Iliac crest = L4/5

Patient 3 – Follow up treatment for shoulder and thoracic pain and restriction
This patient has been returning to the clinic for over 4 months for treatment of the shoulder and thoracic spine. Over this time, his mobility and pain has improved to a point that he is almost free of any symptoms. Each time he returns he reports slight discomfort shortly after treatment which eases within a few days but I always explain that this is to be expected.
This patient usually commits well to his exercises, however on this occasion he had done very little over the previous four weeks. Interestingly, there was no worsening of symptoms from this, therefore we felt confident that over the course of sessions, this patient has developed a good level of stretch and that we have managed the level of rehabilitation appropriately. I was careful to advise the patient to gradually get back into his exercises, as opposed to jumping straight back into it, so as to avoid any overloading of potentially deloaded tendons of his shoulder.
At the point in his rehabilitation, the patient seems to be returning regularly but only for passive sport massage of which he feels benefits him and facilitates his strengthening program.
I am much better at managing my time during sports massage now and ensure that organise my time in chunks of area to massage, so that I do not run out of time and this session seems to go as planned.
Due to an increase in pain over his T3-T4 spinous processes (now that I feel more confident in palpating and identifying them after practicing earlier in the session), I did not perform PA mobilisations as per usual treatment, so as not to irritate any muscle attachments over the site of mobilisations.
I reviewed all of his exercises and went through each one again just to ensure that he is happy with how to perform them, as he hasn’t done them for over a month. I have found from experience that physically demonstrating and practicing the exercises with the patients better ensures their compliance in their home program, as I can make sure that they know what is being asked of them and also the reasons why. Just writing down exercises on a sheet usually is not the most effect, as many patients report losing or misinterpreting the information.

References – 

Cook, J. L., & Purdam, C. R. (2009). Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British Journal of Sports Medicine. https://doi.org/10.1136/bjsm.2008.051193

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

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