Total Hours: 192
External Hours: 50
Patient 1 – Pain in neck and shoulders
My first patient of the evening did not arrive, so I partnered up with a fellow student who was conducting an assessment on the cervical spine and shoulders.
It became apparent early on that this patient was going through a very difficult time at home and as such much of the initial subjective assessment was spend discussing this and listening, which I have come to learn is an incredibly important aspect of our role as therapists. From this, a pattern of pain emerged and the patient herself understood the implications of the stress on her musculoskeletal health. I find it difficult to explain to patients that there may be a psychosocial element to their discomfort, as I do not want them to think that I am suggesting their pain is in their head, however fortunately, this particular patient works in mental health and is intelligent in this area. Nonetheless, we were very sensitive to her struggles and together we provided a calm, relaxed but professional environment and tried to derive a self-management plan for her pain in case she was unable to return to the clinic in the near future.
This patient often worked on computers at work which is commonly associated with forward shoulder posture (Szeto, Straker, & O’Sullivan, 2005), which was evident, although this was not objectively measured only seen through observation and self-reported by the patient.
Because there were two therapists treating this patient, we were able to really engage in conversation with her and listen.
Our objective measure was the endurance test, whereby the patient lies supine and lifts her head off of the couch with chin tucked in for as long as possible; the patient could only last 4 seconds, where expected would be more in the range of 40 seconds!
This indicated to us that the patient should look to strengthen her deep neck flexor muscles and be more consciously aware of her posture. Exercises to increase muscle strength in the thoracic/scapular muscles, combined with stretching of the pectoralis minor muscles have been found to reduce forward shoulder posture and associated pain (Hajihosseini, Norasteh, Shamsi, & Daneshmandi, 2014; Harman, Hubley-Kozey, & Butler, 2005; Kotteeswaran, Rekha, & Anandh, 2012). We prescribed Y exercises using an exercise ball, scapular squeezes, low rows and door frame stretching, all exercises that this patient can do at home and that I have readily prescribed in the past.
When administering soft tissue massage, my fellow student therapist and I both treated a shoulder each, which initially we felt would be more efficient, however we soon realised that because we were so different in our technique, the patient was comparing the pressure and may have felt uneven. Just because I applied more pressure does not necessarily mean it was more effective, so in future I would look to perform treatment on an entirely different area such as the thoracic spine, so that the patient could not compare.
This patient left the clinic in high spirits and felt positive about her treatment and her take home plan. I made sure to ask for feedback throughout to make sure that the patient was happy with her plan to increase the chances of adherence.
Patient 2 – Soft Tissue Massage of TFL and Lateral Hip Abductors
This patient requested soft tissue massage of her “IT Band” only.
Initially, I felt as though this patient was quite reserved and anxious about her treatment due to her quiet and non-conversive manner at the start of the treatment. This was reinforced by her request to treat only one area. In order to better understand any worries my patient might have had, I was sure to ask whether he had had any previous soft tissue massage, to which she replied that she had. This reassured me that she was aware of the procedure and that her anxieties, if any, did not stem from inexperience; sometimes patients can be worried when they do not know what to expect. Nonetheless, I continued to treat this patient sensitively, respecting her choice of minimal communication.
Throughout the treatment, I gave the patient time and space to communicate at her pace if desired but did ask the odd very open question. Quite often I engage in interesting conversations with the patients, which can be flowing, animated and enjoyable however, by appreciating the need of calm and quiet with this particular patient, she eventually did begin to feel more comfortable and open up and by the end of the session. I felt as though I had the opportunity to discuss her running and the reasons why she may be experiencing tightness in her glutes and/or TFL. Communication is an extremely important aspect of sports therapy and if I am able to build a rapport with my patients, any advice that I may offer them may be taken away with a little more confidence and motivation. Although this patient did not present with an injury as such, there was slight discomfort and tension when running.
I advised the patient that although there are benefits to STM and that that treatment would help to relieve tension and manage symptoms (Falvey et al., 2010), this was not the only way to manage a potentially ongoing discomfort and as such we discussed ways for her to self-manage the onset of further discomfort.
As this patient has an intensive running schedule and has been running for years she had established a well thought out training plan that seemed to limit excessive loading or change in load and she understood the implications of not doing so. She was currently spending 10minutes per day performing exercises that she had found herself and reports excellent compliance and effects from this. In my opinion, this patient was self-managing her discomfort excellently and my only advice to this patient was to incorporate an element of stretching into her daily routine, as she had not previously done so. This was because she was unable to find a stretch that targeted the right area. When demonstrating a stretch for this patient, I realised that I wasn’t entirely sure of the most effective method and couldn’t fully work out the correct routine. I had to research this online, as well as ask the clinic supervisor.
We spent quite a long time trying to work out the most effective stretch, based of how the patient felt but to no avail. It became apparent that the patient was experiencing most discomfort more specifically in her glutes and that a gluteal stretch was more appropriate. From my anatomy knowledge I know that the gluteus maximus inserts into the tensor Fascia Latae and I should therefore have tried a number of these stretches first. I have since practiced a range of stretches and have a bit more experience with how to demonstrate these. The stretches in the following video were found to be most effective for this patient;
In order to fully appreciate the efficacy of advising stretches for these, I conducted some research around iliotibial band injuries and associated pain.
ITB syndrome is prevalent among runners and can be seen in between 5 and 15% (van der Worp, van der Horst, de Wijer, Backx, & Nijhuis-van der Sanden, 2012) and is a repetitive use injury that derives from the continuous flexing and extending of the knee.
When treating this patient, I did not take into consideration a differential diagnosis, or at least encourage the patient to consider the potential of other structural involvements, for example bursitis of the bursae on the lateral femoral condyle, as this makes contact with the TFL and could present with symptoms similar to the pain in the ITB or associated structures which the patient assumed was tightness or tension (Falvey et al., 2010). The term ITB syndrome is broad and covers an array of dysfunctions, however the treatment may remain similar to some extent. Any direct pressure on the inflammation should be avoided, such as deep friction massage, especially over the area of bursitis if present, however massage and stretching of the associated structures is advised as well as exercises to target weaknesses in the lateral hip abductors, which this patient had already been doing (Brown, Zifchock, Lenhoff, Song, & Hillstrom, 2019; Falvey et al., 2010; van der Worp et al., 2012).
Research conducted by Brown et al. (2012) challenged the well documented associations between weakness and IT Band syndrome, however they further investigate the effects of duration exercise on fatigue and instead of identifying weaknesses in the gluteal muscles, of which there was no significance, the gluteus Medius muscles were less able to resist fatigue.
From previous research I have learnt that in order to invoke a fatiguing response on muscles to develop their ability to withstand duration of loading, strengthening needs to include higher sets but of lower loads (Reiman & Lorenz, 2011). These are especially useful in postural muscles that have to withstand low levels of load continuously to stabilise the body in rest and activity. So although testing for this patient revealed 5/5 strength that does not mean that he abductors have the optimum ability to withstand fatigue and as such strengthening in conditions of fatigue may be a good focus; I made sure to increase reps of exercises for her home strengthening program.
As I advised my patient, that although the use of STM and foam rolling is a good way to relieve symptoms (Wiewelhove et al., 2019), it is not an effective means of long-term treatment as it does not address the case. Research by Falvey et al. (2010) found that intervention targeted at any shortening of the muscular components of the iliotibial tract, such as the gluteus maximus and tensor fascia latae muscles may be more effective that the IT Band itself which shows little mechanical lengthening at all. This same review found that although there is some evidence to support the use of deep tissue massage, it is no more effective combined with stretching than stretching alone and therefore I feel confident in prescribing a stretching routine for the patient to facilitate their home strengthening routine (van der Worp et al., 2012). I instructed the patient, therefore to continue to strengthen the lateral hip abductors and glutes and to manage symptoms such as tension and tightness using a foam roller and stretching, but of the TFL and glutes as opposed to the IT Band, so as not to irritate any inflammation that may be present.
Throughout my time in clinic, I have tried to remember to test patients before and after treatment or programs using objective markers so that I can measure the effectiveness of treatment and fortunately I knew how best to do so on this occasion. The OBERS test and the modified Thomas test have both been recommended as a means to objectively measure treatment or to pre-screen athletes who may be pre disposed to injury (van der Worp et al., 2012). Although there were no bilateral differences in this patient, the dysfunction experienced in her left side was enough of an indication. This is a useful measure for the patient to take home with her, as she can retest this to measure any changes in pain, in case she does not return to the clinic. I advised her to regularly assess her own levels of discomfort and adjust exercise plan accordingly.
Brown, A. M., Zifchock, R. A., Lenhoff, M., Song, J., & Hillstrom, H. J. (2019). Hip muscle response to a fatiguing run in females with iliotibial band syndrome. Human Movement Science. https://doi.org/10.1016/j.humov.2019.02.002
Falvey, E. C., Clark, R. A., Franklyn-Miller, A., Bryant, A. L., Briggs, C., & McCrory, P. R. (2010). Iliotibial band syndrome: An examination of the evidence behind a number of treatment options. Scandinavian Journal of Medicine and Science in Sports. https://doi.org/10.1111/j.1600-0838.2009.00968.x
Hajihosseini, E., Norasteh, A., Shamsi, A., & Daneshmandi, H. (2014). The Effects of Strengthening, Stretching and Comprehensive Exercises on Forward Shoulder Posture Correction. Physical Treatments – Specific Physical Therapy Journal, 4(3), 123–132. Retrieved from http://ptj.uswr.ac.ir/article-1-170-en.html
Harman, K., Hubley-Kozey, C. L., & Butler, H. (2005). Effectiveness of an exercise program to improve forward head posture in normal adults: A randomized, controlled 10-week trial. Journal of Manual and Manipulative Therapy. https://doi.org/10.1179/106698105790824888
Kotteeswaran, K., Rekha, K., & Anandh, V. (2012). Effect of stretching and strengthening shoulder muscles in protracted shoulder in healthy individuals. International Journal of Computer Application, 2(2), 111–118.
Reiman, M. P., & Lorenz, D. S. (2011). Integration of strength and conditioning principles into a rehabilitation program. International Journal of Sports Physical Therapy.
Szeto, G. P. Y., Straker, L. M., & O’Sullivan, P. B. (2005). A comparison of symptomatic and asymptomatic office workers performing monotonous keyboard work – 2: Neck and shoulder kinematics. Manual Therapy. https://doi.org/10.1016/j.math.2005.01.005
van der Worp, M. P., van der Horst, N., de Wijer, A., Backx, F. J. G., & Nijhuis-van der Sanden, M. W. G. (2012). Iliotibial Band Syndrome in Runners. Sports Medicine. https://doi.org/10.2165/11635400-000000000-00000
Wiewelhove, T., Döweling, A., Schneider, C., Hottenrott, L., Meyer, T., Kellmann, M., … Ferrauti, A. (2019). A meta-analysis of the effects of foam rolling on performance and recovery. Frontiers in Physiology. https://doi.org/10.3389/fphys.2019.00376