Total Hours: 196
External Hours: 50
Clinic Hours: 146

Patient 1 – STM and Quality of life Questionnaire
I was due to see my regular patient today, however this patient cancelled at the last minute leaving me with only one patient today which is a great shame, as I feel as though I have missed out on many learning opportunities over the past few months and also the ability to record valuable clinic hours to add to my log. I also did not get to hand out a quality of life questionnaire which I was excited to trial, however I believe the patient has rearranged again for a week’s time; I will be well prepared.

Patient 2 – Pain and swelling in knee from trauma 6 months ago; awaiting knee surgery through NHS.
This patient was an elderly lady who arrived to the clinic with her husband. When greeting her, I took the opportunity to start my observations as she got out from her seat and made her way to the cubicle; she needed walking aids and her husband for extra support. I was quite shocked by the amount of swelling in her knee and the obvious discomfort that she was in and I feel like it affected me, however I was sure to remain professional when discussing her action plan.
In my time at the clinic, I hadn’t come across a patient who has been affected so much in her family life, not only by reduced functional ability but by significant pain. When going through the subjective assessment, my patient got very emotional which to me, was a major indicator as to how much this was affecting her; I reassured her that I would do what I could to ensure that she had a good plan of action to take away with her.
After a short discussion with the manager, it dawned on me how important follow up appointments are and that the patient can just as easily cancel if they don’t feel the need to attend. By offering this patient a follow up, I am offering our services as a long-term care plan, as opposed to leaving the treatment without end; the patient may feel as though we have done all that we can and that there is little we as a clinic can add. Although I did suggest returning for further advice or treatment, but actually booking something adds continuity of service and peace of mind for an appointment in the near future, unlike the NHS and their challenging appointment process at times.

With regards to the exercise prescription, both the clinic manager and I agreed that a program of simple exercises to strengthen to knee would help to relieve pain and better support the join to reduce symptoms but it was our belief that this would better improve the outcome of knee replacement surgery as shown in a review by Wallis & Taylor (2011).
However, according to Gill & McBurney (2013) in a and meta-analysis of RTCs regarding knee and hip surgery and the prescription of exercise pre surgery, although hip outcome measures improved from a pre-surgery exercise program, pre knee surgery patients experienced no significant difference in outcome scores. I was surprised by this; however I would still advocate the use of strengthening as it did not seem to have any negative affect on the patients but in my opinion only provides hope and focus for those awaiting surgery. Reviews may not always include all research available and they are not without their limitations, for example Gill and McBurney (2013) and did not include psychological elements to their outcome measures and included 18 RTCs whereas Wallis & Taylor (2011) included 23.

When demonstrating and going through the sit-to-stand, I felt pleased knowing that I had come up with the initiative to get a non-wheelie chair. Often, with elderly patients they struggle to use the movable chairs and I was very aware that this would have proved difficult for this patient. I did not use a lowered treatment bench either, as this did not have handles. In the absence of a chair in future, I could have offered my hands as support, but know that something this may feel uncomfortable for the patient. I also wanted to create a scenario of exercise which the patient could take home with them and do by herself.

I was quick to request assistance from the clinic manager, as I was initially taken aback by the inflammation and obvious pain and dysfunction, however over the course of the session I realised that I was probably far more capable than I realised at the time. Unfortunately, there isn’t much immediate pain relief that I could have offered the patient at the clinic, as much as I would have loved to do. I did make sure that I offered her plenty of reassurance as to the outcome of the session, her cooperation to strengthening and the prospects of surgery in the near future. I feel that the patient felt happier leaving the clinic than arriving and I hope that by calling her for a follow up to find out progress and offer further treatment, I may be able to see for myself the differences that strengthening has made on her pain, function and perception of pain.

References –

Gill, S. D., & McBurney, H. (2013). Does exercise reduce pain and improve physical function before hip or knee replacement surgery? A systematic review and meta-analysis of randomized controlled trials. Archives of Physical Medicine and Rehabilitation. https://doi.org/10.1016/j.apmr.2012.08.211

Wallis, J. A., & Taylor, N. F. (2011). Pre-operative interventions (non-surgical and non-pharmacological) for patients with hip or knee osteoarthritis awaiting joint replacement surgery – a systematic review and meta-analysis. Osteoarthritis and Cartilage. https://doi.org/10.1016/j.joca.2011.09.001