Running total of hours – 179.5

Patient 1 –
The rehabilitation sessions for this patient had focused primarily on thoracic mobility and exercises to facilitate full pain free ROM, advancing to strengthening with the end goal of increasing strength and shoulder proprioception to prevent future injury. Good progress was made at the beginning of the treatment sessions, with good patient satisfaction and noticeable improvements in clinical markers such as pain and ROM. As symptoms did not completely subside, I looked into identifying other possible factors that may have been causing the pain, to which I found potential asymmetry in scapular motion and possible weakness in the patient’s serratus anterior muscles bilaterally and shortened pectoralis muscles. Since incorporating the scapular stabilisation exercises, the patient has further reported improvements in his symptoms and a greater awareness of his posture. The exercises that I gave the patient were appropriate, however I did need to review his technique during this session as he was still unsure as to the positioning of his body. He did not perform the push ups against the wall, he went straight to the floor as he felt that this would have challenged his proprioception more. This was advised by myself, however I need to make it clear that the patient is aware of the need to practice the correct muscle firing patterns and scapular alignment in simpler exercises before progressing exercises too soon, as this would risk under activating of the right muscles needed for correct movement.

From revising earlier reflections on my sessions with this patient, in particular a session in November 3^rd 2019, I noticed that progress was excellent at the beginning of treatment and the patient reported much less pain and more range of motion from the treatments and exercise prescription at the time, however it was my aim from that point to reduce this patient’s dependence on the clinic. After a discussion with this patient in this most recent session, I was reassured that the patient now had a much better understanding of the reasons for the particular exercises and now has the knowledge in how to progress these activities himself in a gym or home setting. His reliance on the clinic has also gradually decreased with sessions occurring monthly as opposed to fortnightly. The thoracic spine exercises prescribed in the session dated back to November were incorporated into this patient’s rehabilitation early on, to which he reported good self-adherence, however clinical measures did not seem to indicate any further increases in mobility, nor a continuing deficit. Since progressing assessment and using the symptom modification procedure to add another dimension to this patient’s treatment, focusing more on scapular stabilisation and serratus anterior activation, these exercises were no longer required in such large volumes on a week to week basis. Instead, focusing more on rotator cuff strengthening and scapular stabilisation exercises would be more effective in enhancing this patient’s strength and reducing the risk of further injury. Mobility exercises can be performed regularly as a means of maintenance but do not need to form the basis of rehabilitation as his mobility is, at this stage, excellent.

To further enhance this patient’s rehabilitation, now that he has regained full strength and ROM in his shoulders and good mobility in his thoracic spine, I will look to progress his exercises to incorporate more proprioception and then plyometric work to not only facilitate the strength and pain free range of motion in his everyday tasks and occupational workload, but to enhance his gym abilities and to help reduce the risk of future injuries.

Patient 2 – Recent Tibial Tubercle Osteotomy for Patellofemoral Instability on Rt, presenting with similar symptoms on Lt.
This patient is a young female who has recently had surgery (4/12 ago) on her Rt knee to treat recurring dislocations, which involved the re positioning of the patella by way of completely detaching the tibial tubercle and attached patella insertion, to be relocated medially; shifting the whole quadriceps and patella complex (Caton & Dejour, 2010). This left the patient with a difficult rehabilitation program, from which she sought from the clinic shortly after her surgery. The rehabilitation plan involved strengthening of her core, lower back and lateral hip muscles as well as addressing imbalances in hamstrings, adductors and quadriceps.
The patient had returned to the clinic as she would like to return back to rugby, but due to the instability in her non surgically treated knee (this had also dislocated twice in recent months), she feels apprehensive about playing and also finds it painful to run; reporting a 7 out of 10.
After a thorough assessment, bilateral functional weaknesses in her knees were evident by way of her inability to stabilise her motion during a single leg squat. Bilateral tightness in her hip flexors and quadriceps were also apparent with additional knee valgus and internal rotation of the hip. At first I wondered if this was due to apprehension and fear of re-injury, however from communicating sensitively with this patient, this may not have been the most influencing factor, as she self-reported minimal fear in this particular movement, but in explosive playing movements only.
This patient has experienced reoccurring knee dislocations in both knees, which can be indicative of needing surgical treatment, criteria specifically reported as “objective patellar instability with true dislocation of the patella with or without patella alta and trochlear dysplasia” (Caton & Dejour, 2010 p309). MRI imaging of her right leg confirmed the need for patella repositioning; however she has not yet been referred for imaging of her right leg due to the short term nature and recent onset of the left leg instability. The only clinical symptoms for this leg have been the dislocations.
I found this appointment really challenging because I have not yet experienced knee instability at such a degree and I was concerned that I would cause further damage or potentially risk dislocation. I also find it difficult to fully identify and isolate the muscles that are the weakest and to develop a program most suitable for the needs of an individual. I felt as though I had lost all of my confidence and had to seek advice from the clinic manager, who shared a wide variety of strengthening exercises focusing mostly on quadricep strengthening, which now I have reflected upon the treatment, I can understand the need behind this, due to the potential complications from the surgery and the need to prevent dislocation in the other knee. I should have focused on the location of the injury site and the rationale behind the surgery to have determined the need for quadricep strengthening.
I was, however, confident in identifying hip abductor weaknesses and the need for abduction strengthening exercises to improve hip and knee strength by way of decreasing knee valgus and hip internal rotation. I was able to learn from previous treatments, the value of the bridge exercise with additional resistance bands around the thighs or progressed to around the ankles to activate abductors (Choi et al., 2015) and the clam exercise with resistance bands, again around either the ankle or the thigh (Willcox & Burden, 2013).
This session highlighted an area of confidence and knowledge that I am lacking, however from this, I can better appreciate the importance of keeping it simple and starting with simple exercises and using each individual as an indicative marker as to their readiness for progression. This patient found 5kg of weight on a leg press a 7/10 excursion but was doing 4 sets of 12 and was feeling no additional benefits from this, being unable to progress to bigger weights. Although the weights seem relatively low, considering the patient’s usual workload of rugby and gym sessions, I would be tempted to look to increase this, however as she had such a high exertion for such a low load, I had to approach this differently. Instead, I looked to find ways to reduce the patient’s perceived exertion before progressing weights. By reducing the patient’s reps to 10 and the sets to 3, I gave my patient the goal to reduce effort to as little as 3/10 before increasing the weights on the leg press. This not only gave the patient a goal, as I often miss in my sessions, but it gave us a means to determine how to adjust reps and sets. I advised the patient to further reduce these if no improvements were felt, which may have helped to empowered her to take responsibility for her own routine to some extent.
By using exertion as a measure instead of weights and reps and sets, it offers the patient another dimension to their ability to understand their progression a little better, especially for patients who are not used to gym equipment or have access to equipment than offer weight increments.
This approach to muscular strength also looks to address the neurological responses to muscular activation and the athlete’s perceived ability to perform movements are more closely analysed as opposed to more numerical, objective targets.

References –

Caton, J. H., & Dejour, D. (2010). Tibial tubercle osteotomy in patello-femoral instability and in patellar height abnormality. International Orthopaedics, 34(2 SPECIAL ISSUE), 305–309. https://doi.org/10.1007/s00264-009-0929-4

Choi, S. A., Cynn, H. S., Yi, C. H., Kwon, O. Y., Yoon, T. L., Choi, W. J., & Lee, J. H. (2015). Isometric hip abduction using a Thera-Band alters gluteus maximus muscle activity and the anterior pelvic tilt angle during bridging exercise. Journal of Electromyography and Kinesiology, 25(2), 310–315. https://doi.org/10.1016/j.jelekin.2014.09.005

Willcox, E. L., & Burden, A. M. (2013). The influence of varying hip angle and pelvis position on muscle recruitment patterns of the hip abductor muscles during the clam exercise. Journal of Orthopaedic and Sports Physical Therapy. https://doi.org/10.2519/jospt.2013.4004

Running Total of hours: 177

Patient 1 – Knee Pain
My first patient reported with pain in her right knee, more specifically over the pes anserine tendon.
From earlier research I discovered an effective array of tests including the patella apprehension test, the active instability test and the eccentric step tests which, combined, both have a sensitivity and negative predictive value of 100% (Arjun and Chouhan, 2017), however this remained inconclusive with pain very localised to a small area on her medial proximal tibia and I did not feel as if this was fully indicative of a patella issue, as most commonly reported with anterior knee pain. As I have previously found the single leg squat to be an effective observative measure of lateral hip muscle weakness and hip internal rotation during a more functional movement (Ugalde, Brockman, Bailowitz and Pollard, 2015), I asked the patient to perform this.
In the initial squat, I was unable to observe significant excessive angles or pain, so I asked the patient to perform the movements continuously up to 15 times to reproduce the most repetitive motions of her sport; walking netball and to reproduce an element of fatigue which is more likely to bring on or exasperate the patient’s poor technique, pain and/or excessive internal rotation and knee valgus. After the first 5 squats, the patient did start to experience greater levels of pain and more exaggerated hip angles and therefore I was able to explore the options of rehabilitation to include lateral hip strengthening, but potentially while in a more fatigued state so as to condition the muscles in a more task specific manner.
In my previous reflections I read about the importance of core stability in the treatment and prevention of anterior knee pain (Ferber, Bolgla, Earl-Boehm, Emery and Hamstra-Wright, 2015) and the prevention of lower limb injuries in general (De Blaiser et al., 2018) and as such looked to incorporate this early on in this patient’s treatment. I was reassured to learn that she had already started a program prescribed to her by her doctor called the ‘Escape Pain App’ and I took the time to go through this with my patient as it seemed to be a great means to enhance patent adherence. The App had goals, targets and checklists, which had all been fully utilised by the patient. As the patient has reported improvements since the start of this program with much of the focus on core stability, I can be assured that clinically and for pain reduction and lower limb stability, core exercises such as bridges and side lying bridges are an effective strategy. As I have previously found supporting evidence for abduction exercises to increase hip abduction strength, I included the use of a resistance band around the patient’s ankles during side lying abduction to increase the resistance and also around the patients thighs during the bilateral bridge as this has also been found to increase abductor muscle activation (Choi et al., 2015).
I also understood the need to add varying exercises to the patient’s rehabilitation plan as at least they have a fall back option in case they are unable to remember the technique of one of the exercises for example, so in this case I gave the patient a range of exercises to target the abductors, including the clam exercise, which has also been found to activate and strengthen the hip abductors (Macadam, Cronin and Contreras, 2015).
This patient wanted reassurance that she was able to re-join her walking netball club and continue to play knowing that she would not be causing any damage to the structures in her knee, to which I was able to reassure her that this would be a positive and recommended move forward providing that she was continuing to strengthen her hip and knee to facilitate her knee stability and reduce her excessive hip angles.

Patient 2 and 3 cancelled their appointments before the clinic session so unfortunately I was not able to gain any extra practical, hands on experience on this occasion, however I used the time to create a learning opportunity for myself and other patients by discussing our knowledge and understanding of dermatomes and myotomes, an area that I struggle with, as unfortunately due to the nature of my completion of my foundation degree, this is not an area we cover in depth.
Whenever there is a gap in treatments and all notes are up to date and checked, I ensure that I take the time to visit other students within the clinic between their patients to ask them about their case studies and to discuss their methods of treatment.
In the theory sessions of clinical practice, we are currently going through various different case studies and I have found this incredibly useful. Each individual case is different and from practicing a thorough breakdown of assessments, including objective and subjective information, I learn new ideas of how to identify diagnostic clues unique to each case.
For example, each sport has different biomechanical demands on the athletes and by breaking down their movements and asking them to perform their sporting actions can lead to clues in their dysfunction; findings from static and single plane tests may be indicative of pathology but never conclusive without a more dynamic, sports or activity specific movement breakdown whereby symptoms may be reproduced. In the instance of pain, analysis of specific sporting movements may identify muscular imbalances, dysfunction and/or compensatory responses, which are often the primary culprit and clue as the cause of the pain.
With this in mind, engaging in a discussion with other students about the unique nature of their cases and diagnostic findings may help to add extra ideas and tools for myself to potentially explore in my initial assessments, especially with patients who take part in sports requiring very specific movement patterns.

Patient 4 – Follow up hip and lower back soft tissue massage
This was a regular patient who visits the clinic and receives a maintenance treatment for lower back and hip pain and as much as I advise this patient on the benefits of self-maintenance, this patient is more than happy to continue to visit the clinic for symptom management. I used this time to practice my massage techniques, but this use of manual techniques on a strong individual such as this patient was an important opportunity to maintain my levels of fitness.
It is usual in this practice to have to treat patients back to back who require a significant amount of physical treatments such as soft tissue massage and joint mobilisations and in this particular case, manual hip traction. I find this particularly difficult and labour intensive and I am aware of the impact that this treatment may have on myself as a therapist. It is widely reported that work related musculoskeletal disorders and pain are prevalent among physical therapists (Vieira et al., 2016) and because of the varying nature of the treatments that I offer, from physical therapy to simply verbal communication and patient education and advice, the inconsistency does not always give me the chance to keep fit enough to follow through an entire treatment session of massage and to avoid developing my own injury. From my experience and research, I have come to develop my techniques in this area to avoid fatigue or injury, however there are certain treatments that I may always find difficult, whatever technique I adopt. For example, I found that I was unable to perform the hip traction technique for the length of time that I felt was required for this patient. From this, I should aim to develop my general strength and stamina outside of the clinic, but also to fully utilise these sessions as a way to do this.

Patient 5 – Follow up Scheuemann’s Kyphosis; management of symptoms and a strengthening program
This patient is also a regular at the clinic and is currently following a rehabilitation program that focuses on relieving symptoms of forward shoulder posture and excessive thoracic spinal curvature by way of stretching the posterior capsule and strengthening upper back muscles such as the rhomboids and lower and middle trapezius muscles.
From my reflections in my previous session with this patient, I highlighted the need to remain vigilant in identifying any changes in symptoms and to be aware that I do not become complacent in my approach to this subject because of the frequency of his appointments. I therefore made sure to carry out a full assessment of his shoulder, similar to his initial appointment, to ensure that nothing has been missed and any improvements or deficits are identified.
Interestingly, where there was previously a small bilateral deficit in internal rotation, tests showed a much more significant restriction in this movement on both sides; lack of internal rotation was very obvious to the extent that bilaterally, there was very little ROM. In between appointments with myself, this patient had an appointment with another therapist who performed deep tissue massage to the sub scapular muscles, which felt painful to the patient at the time, but relief was reported from three days after the treatment. If I had been more vigilant, I would have associated this pain with potential weakness and looked to treat the potential cause of the pain, as opposed to treat the tight symptoms by massage. These findings will have a significant impact on the focus of the patient’s rehabilitation for the coming weeks and also an impact on the direction of treatment for this particular session, highlighting the need to be consistent and through at each session, despite the time it may take and potential repetitiveness of this process. From these findings, therefore, in addition to this patient’s regular treatment, I looked into incorporating additional exercises that will help to increase internal rotation before continuing with strengthening the shoulder muscles.
I suggested the sleeper stretch and explained to the patient about the need to hold the stretch for at least 30seconds. When I explained this to the patient, he was genuinely surprised to have learned that he was not holding his stretches long enough. I usually stress the importance of holding the strength for at least 25-30seconds and I also ensure that I write this on their rehabilitation card, however it was clear that I did not explain this concept well enough to this patient early enough and as such, previous stretches may not have had the desired effect. This further highlights the need to review not only the exercises themselves and how well the patient can perform them, but review the patient’s understanding of the reasons why they are doing them and why they follow particular methods.
It will be interesting to review any potential progression in ROM in internal rotation over any following sessions, but also in his posture by way of the door frame stretch and lengthening the area of his chest associated with the length of his pectoralis minor (Carvalho et al., 2019; Finley et al., 2017; Rosa, Borstad, Pogetti and Camargo, 2017).

In previous weeks I have also discovered theories suggestive of the benefits of scapular alignment in relation to shoulder muscular imbalances that can contribute to varying movement patterns and weaknesses in the shoulder, for example in research by Cools et al. (2014) and Lewis (2011). I have learnt that although muscle activation patterns are maintained throughout entire movements, such as through flexion and extension (Reed, Cathers, Halaki and Ginn, 2016), that is not to assume that the correct levels of activation are being achieved in the initial movements and as well as ensuring that this patient is improving internal rotation ROM before more strengthening, I wanted to ensure that his scapular stabilisation and movement patterns were not causing additional dysfunction. I am new to the concept of scapular dyskinesis but as I have developed a theoretical trust in this identifying feature to possible shoulder pain and dysfunction, I was enthusiastic to incorporate this into my assessments. In order to identify any dyskinesis, I asked the patient to perform bilateral forward flexion of the shoulder, followed by bilateral shoulder abduction with a dumbbell in each hand, a method derived by McClure, Tate, Kareha, Irwin and Zlupko (2009). Because the patient was over 68kg in weight, the dumbbell weight was 2.3kg (1.4kg for patients over 68kg). From this, I identified both early protraction and early elevation of the scapular. This test was found to have good intra rater reliability and therefore of clinical relevance in this instance (McClure et al., 2009).
I am yet to fully understand whether the prematurely protracted and elevated scapular is of significance in this particular case, as the movements dysfunction is bilateral and it is unclear as to whether this contributed to excessive kyphotic posture or whether the scapular muscle weaknesses have occurred as a result of the onset of Scheuemann’s kyphosis.
Apart from being a great opportunity to develop my confidence in my ability to identify dysfunction, but by carrying out this method of analysis/observation, it was a chance to explore other treatment directions, especially as this patient has had little to no relief in muscular pain in the muscles stabilising and assisting in moving the scapular; specifically the rhomboids. I am able to suggest that, although the findings of the scapular dyskinesis test led me no further forward in understanding any potential imbalances, it did allow me to identify a bilateral weakness in his rhomboids and as such I felt confident in suggesting more scapular stabilisation exercises, such as low rows and Y and L shoulder exercises, as advocated by Liebenson et al. (2011). Due to the high levels of gym activity of this patient, I suggested that he perform these exercises lying prone on an exercise ball, so as to advance this to incorporate additional core stability and balance and coordination, areas usually of weakness amongst the general population (De Blaiser et al., 2018; Huxel Bliven & Anderson, 2013). I also explained the importance of correct scapular alignment and use of correct muscle groups and posture when doing these exercises and used posture ETT in order to enhance sensory reception and subsequent consciousness of posture. (Han, Lee and Yoon, 2015; Shaker, Keshavarz, Arab and Ebrahimi, 2013). This patient has always returned to the clinic reporting significant benefits from the use of kinesiology tape and requests this as an additional element to treatment. Whether the effects of this tape are due to placebo, as commonly reported (Poon et al., 2015) or whether the benefits of this patient were felt as a result of the treatment itself as opposed to the tape, patient satisfaction prevails in this instance and I was confident in the efficacy to apply ETT as an effective mode of treatment.

References –

Arjun, K. R., M. S., D., & Chouhan, D. (2017). Reliability of clinical methods in evaluating patellofemoral pain syndrome with malalignment. International Journal of Research in Orthopaedics, 3(3), 334. https://doi.org/10.18203/issn.2455-4510.intjresorthop20170902

Carvalho, L. A. C. M., Aquino, C. F., Souza, T. R., Anjos, M. T. S., Lima, D. B. M., & Fonseca, S. T. (2019). Clinical Measures Related to Forward Shoulder Posture: A Reliability and Correlational Study. Journal of Manipulative and Physiological Therapeutics, 42(2), 141–147. https://doi.org/10.1016/j.jmpt.2019.03.006

Choi, S. A., Cynn, H. S., Yi, C. H., Kwon, O. Y., Yoon, T. L., Choi, W. J., & Lee, J. H. (2015). Isometric hip abduction using a Thera-Band alters gluteus maximus muscle activity and the anterior pelvic tilt angle during bridging exercise. Journal of Electromyography and Kinesiology, 25(2), 310–315. https://doi.org/10.1016/j.jelekin.2014.09.005

Cools, A. M. J., Struyf, F., De Mey, K., Maenhout, A., Castelein, B., & Cagnie, B. (2014). Rehabilitation of scapular dyskinesis: From the office worker to the elite overhead athlete. British Journal of Sports Medicine, 48(8), 692–697. https://doi.org/10.1136/bjsports-2013-092148

Craig Liebenson, D. C. (2011). Y exercises for correcting the most common faulty movement pattern of the shoulder/neck region. Journal of Bodywork and Movement Therapies, 15(3), 391–394. https://doi.org/10.1016/j.jbmt.2011.05.001

De Blaiser, C., Roosen, P., Willems, T., Danneels, L., Bossche, L. Vanden, & De Ridder, R. (2018). Is core stability a risk factor for lower extremity injuries in an athletic population? A systematic review. Physical Therapy in Sport. https://doi.org/10.1016/j.ptsp.2017.08.076

Ferber, R., Bolgla, L., Earl-Boehm, J. E., Emery, C., & Hamstra-Wright, K. (2015). Strengthening of the hip and core versus knee muscles for the treatment of patellofemoral pain: A multicenter randomized controlled trial. Journal of Athletic Training, 50(4), 366–377. https://doi.org/10.4085/1062-6050-49.3.70

Finley, M., Goodstadt, N., Soler, D., Somerville, K., Friedman, Z., & Ebaugh, D. (2017). Reliability and validity of active and passive pectoralis minor muscle length measures. Brazilian Journal of Physical Therapy, 21(3), 212–218. https://doi.org/10.1016/j.bjpt.2017.04.004

Han, J. T., Lee, J. H., & Yoon, C. H. (2015). The mechanical effect of kinesiology tape on rounded shoulder posture in seated male workers: A single-blinded randomized controlled pilot study. Physiotherapy Theory and Practice. https://doi.org/10.3109/09593985.2014.960054

Huxel Bliven, K. C., & Anderson, B. E. (2013). Core Stability Training for Injury Prevention. Sports Health. https://doi.org/10.1177/1941738113481200

Lewis (2011). Shoulder Symptom Modification Procedure ( SSMP ) V2 Date : Symptomatic movement or posture 1 : Symptomatic movement or posture 2 : (1), 2011.

Macadam, p., Cronin, j., & Contreras, b. (2015). An examination of the gluteal muscle activity associated with dynamic hip abduction and hip external rotation exercise: a systematic review. International journal of sports physical therapy.

McClure, P., Tate, A. R., Kareha, S., Irwin, D., & Zlupko, E. (2009). A clinical method for identifying scapular dyskinesis, part 1: Reliability. Journal of Athletic Training. https://doi.org/10.4085/1062-6050-44.2.160

Poon, K. Y., Li, S. M., Roper, M. G., Wong, M. K. M., Wong, O., & Cheung, R. T. H. (2015). Kinesiology tape does not facilitate muscle performance: A deceptive controlled trial. Manual Therapy. https://doi.org/10.1016/j.math.2014.07.013

Reed, D., Cathers, I., Halaki, M., & Ginn, K. A. (2016). Does load influence shoulder muscle recruitment patterns during scapular plane abduction? Journal of Science and Medicine in Sport, 19(9), 755–760. https://doi.org/10.1016/j.jsams.2015.10.007

Rosa, D. P., Borstad, J. D., Pogetti, L. S., & Camargo, P. R. (2017). Effects of a stretching protocol for the pectoralis minor on muscle length, function, and scapular kinematics in individuals with and without shoulder pain. Journal of Hand Therapy, 30(1), 20–29. https://doi.org/10.1016/j.jht.2016.06.006

Shakeri, H., Keshavarz, R., Arab, A. M., & Ebrahimi, I. (2013). Clinical effectiveness of kinesiological taping on pain and pain-free shoulder range of motion in patients with shoulder impingement syndrome: a randomized, double blinded, placebo-controlled trial. International Journal of Sports Physical Therapy, 8(6), 800–810. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/24377066%0Ahttp://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=PMC3867073

Ugalde, V., Brockman, C., Bailowitz, Z., & Pollard, C. D. (2015). Single Leg Squat Test and Its Relationship to Dynamic KneeValgus and Injury Risk Screening. PM and R. https://doi.org/10.1016/j.pmrj.2014.08.361

Vieira, E. R., Svoboda, S., Belniak, A., Brunt, D., Rose-St Prix, C., Roberts, L., & Da Costa, B. R. (2016). Work-related musculoskeletal disorders among physical therapists: An online survey. Disability and Rehabilitation. https://doi.org/10.3109/09638288.2015.1049375

Running Total Hours: 172

Patient 1 – STM of neck and shoulders, follow up appointment
This was a follow up appointment for an elderly lady with restricted ROM in the shoulders and neck. I regularly see this patient but very much as a means of social interaction and transient relief of low-level pain and disability. I have reflected on my sessions with this patient and have gone into detail about the efficacy of this and feel as though I am able to offer a service of more than just musculoskeletal therapy. This patient enjoys attending the clinic as a weekly or fortnightly routine as a way of social interaction; at present her home situation is causing her a great deal of stress with her husband’s health in rapid declining. I offer her advice on her daily functions and put my efforts into encouraging her to commit to her exercises more regularly, to be able to maintain more functional movement with less pain for longer and with less reliance on me. I have tried to come up with a range of stretches and exercises that can be done easily and around the home, as it has been reported that adherence to physical exercises rehabilitation programs can be associated with their relation to daily living tasks and how easily the program can be incorporated into every day activities (Bassett, 2015).
Together, my elderly patient and I come up with ways to do this, including movements to get items out of high cupboards for shoulder flexion and stretching her pectoralis muscles when walking through each doorway.
I always make sure I check on progress with pain and function and her perceived ability to perform the exercises as well as ensuring the program goals are met.

Patient 2 – Scoliosis follow up
In the previous session with this patient, It became apparent early on that adherence to the home based exercises program that was prescribed was low to non-existent.
Because I remembered to clinically measure my patient’s level of functional ability by way of an objective marker (in this instance, unilateral hip flexion similar to the Trendelenburg test protocol was done). Due to the instability in his right side while flexing his left hip, we used this clinical measure as an exercise in order to improve muscular strength and balance in the unstable side.
Unfortunately, even though it was a basic exercise to perform as a start to his rehabilitation program, he self-reported his non-compliance. Because of this, no changes in stability were observed and although I was keen to continue to progress the exercise, it was important for me to manage the client’s progress on an individual basis and in this case we did not progress the exercise.
I communicated well with the patient, trying to deduce why the exercise was not done at home and asked whether there was any way that we could, as a team, adapt it to better suit his expectations or ability to which we agreed it was his mindset that needed managing not the exercise. In the last session reflections, I felt as though I had made progress with this patient’s motivation based on the information that I had sought and educated him with since the initial assessment.
It was reassuring, therefore to be able to reassess this patient on his third session to observe significant progress in this test; the unilateral hip flexion motions were almost symmetrical and I was sure to offer a considerable amount of positive reinforcement for this.
I was enthusiastic to progress the patient to more functional and dynamic movements, but without effecting adherence, so I looked to build alterations and progression slowly by adding a new dimension of rehabilitation; proprioception, as this has been associated with and widely used in, the prevention of a number of musculoskeletal pathologies

Proprioception
In a recent review by Blecher et al. (2018) the mechanisms and importance of proprioception are discussed and associations between this element of neurophysiology and musculoskeletal function are addressed.

In this review, proprioception is described as “a component of the sense of the relative position of one’s own body parts as well as of the level of effort exerted by acting muscles” (Blecher et al., 2018 p. 1) and involves two mechanoreceptors; the Golgi tendon organs (GTOs) and muscle spindles which act to either generate force or modulate muscle tension and length.

Both length and tension are modulated by mechanoreceptors (specifically spindle fibres and GTO) by way of managing the load applied onto the soft tissue in order to maintain the functionality and configuration of the skeleton (Blecher et al., 2018).

Interestingly, this article pays particular attention to the association between proprioception and spinal alignment, finding that neuromuscular systems may have an influence on the prevalence of idiopathic scoliosis, particularly as neurological impairments in function and structure within the central nervous system, the somatosensory, vestibular and trunk muscles of those with scoliosis (Blecher et al., 2018).
This study reviewed research conducted on mice, in which close associations between abnormal neurophysiological function and spinal deformities such as scoliosis were made and therefore reported the potential benefits of proprioceptive training in the management of such conditions. The study was also suggestive of the possible link between proprioception and a wider range of musculoskeletal injuries or dysfunction based on these initial findings and although further research is suggested, it forms a basic understanding for myself or other clinicians into the possible links between skeletal alignment and the importance of neurodynamic function.

With this in mind, I wanted to incorporate a large focus on proprioception into this training program and as such conducted research around general proprioceptive principles and application.
Findings suggest that balance and proprioception training has been found to improve posture and neuromuscular motor control (Zech et al., 2010). In an article by Martinez-Amat et al., (2013), a 12-week training program was derived and found to be effective in improving static and dynamic balance and postural stability and although this was a study conducted on the older population, many of the exercises can be appropriate for this patient, especially as he is relatively sedentary with regards to active daily living.

This program shown in Martinez-Amat et al., (2013 p.2183) and available via the link below consisted of a warm up and a cool down with 30 minutes of proprioception in between involved 2 sets of 10-15repetitions of up to 5 different initial stage exercises with gym balls and then 2 sets of 15 seconds using balance boards for the later stages.

https://journals.lww.com/nsca-jscr/Fulltext/2013/08000/Effects_of_12_Week_Proprioception_Training_Program.18.aspx

Although these are basic level drills, I would be able to enhance these to suit each case individually, adapting them by removing variables, for example asking the patient to do the exercises unilaterally, without holding on or with their eye closed to enhance the need to recruit and develop alterative sensory mechanisms. My temptation would be to ask the patient to stand on an uneven surface or movable object, however I have since read an interesting article to suggest otherwise. I have always assumed the theory of proprioception on unstable surfaces and uneven devices, however Ogard (2011) starts to address the physiology and mechanisms of this, questioning the rationale and therefore effectiveness in this method of training.
It was reported that performing exercises on an uneven surface would only serve to recruit other means of sensory mechanisms, such as vestibular and visual information instead of enhancing the somatosensory input, which is the aim of proprioceptive training; proprioception cannot be training if proprioceptive input is not accurate and therefore training on a level surface and modulating other sensory input to apply more emphasis on the somatosensory information input would be more appropriate (Ogard, 2011). This could be by closing eyes to remove visual cues or letting go of support to remove touch.

This effective program could serve as a basic guideline for any future sessions within which I hope to incorporate proprioception on a more basic scale, especially for older patients, whereby gait and balance are impaired; two significant risk factors for falls among the elderly population, as exercise as a sole intervention has been reported as being effective in reducing the likelihood of falls (Sherrington et al., 2017).

For this patient I prescribed the same single hip unilateral hip flexion exercise but with eyes closed or without holding on, which when having a go in the clinic he found much harder and asymmetry was again observed. In his next session, I would hope to see the patient gain symmetry in this motion before progressing further.

Patient 3 – Shoulder/thoracic spine follow up
In my previous session with this patient, due to a time management issue, I wasn’t able to pre read his clinical notes and as such it was obvious to myself and the patient that I had not fully prepared for the session. I was able to accept responsibility for this poor professionalism and ensure that on future occasions, I have fully prepared for each session as much as possible, which is what I did on this follow up appointment. I was sure to be fully ready for my patient so that the beginning of the session went smoothly and no time is wasted during treatment. This session was similar in nature to all past sessions with this patient and was just another maintenance treatment involving soft tissue massage, central mobilisations and stretching. With regards to my ability to perform this treatment, I felt confident in my rationale and physical application, however learnt early on that PA mobilisations are difficult to do with too much massage lotion!

References – 

Bassett, S. (2015). Bridging the intention-behaviour gap with behaviour change strategies for physiotherapy rehabilitation non-adherence. New Zealand Journal of Physiotherapy, 43(3), 105–111. https://doi.org/10.15619/nzjp/43.3.05

Blecher, R., Heinemann-Yerushalmi, L., Assaraf, E., Konstantin, N., Chapman, J. R., Cope, T. C., … Zelzer, E. (2018). New functions for the proprioceptive system in skeletal biology. Philosophical Transactions of the Royal Society B: Biological Sciences, 373(1759). https://doi.org/10.1098/rstb.2017.0327

Martinez-Amat, A., Hita-Contreras, F., Lomas-Vega, R., Caballero Martinez, I., Alvarez, P. J., & Martínez-Lopez, E. (2013). Effects of 12-week proprioception training program on postural stability, gait, and balance in older adults: A controlled clinical trial. Journal of Strength and Conditioning Research. https://doi.org/10.1519/JSC.0b013e31827da35f

Ogard, W. K. (2011). Proprioception in sports medicine and athletic conditioning. Strength and Conditioning Journal. https://doi.org/10.1519/SSC.0b013e31821bf3ae

Sherrington, C., Michaleff, Z. A., Fairhall, N., Paul, S. S., Tiedemann, A., Whitney, J., … Lord, S. R. (2017). Exercise to prevent falls in older adults: An updated systematic review and meta-analysis. British Journal of Sports Medicine. https://doi.org/10.1136/bjsports-2016-096547

Zech, A., Hübscher, M., Vogt, L., Banzer, W., Hänsel, F., & Pfeifer, K. (2010). Balance training for neuromuscular control and performance enhancement: A systematic review. Journal of Athletic Training. https://doi.org/10.4085/1062-6050-45.4.392

Running total of hours: 168.5

Patient 1 – Follow up for lower back STM, hip traction and piriformis release and patient 2 – Scheuermann’s kyphosis.
These sessions were follow ups for regular patients who simply requests the same treatment on a fortnightly basis. Although this does not provide me with the most optimal learning experience, as I am not able to build upon a progressive treatment plan, observe significant improvements or apply new techniques, it does give me the opportunity to practice my techniques for soft tissue massage and although I feel as though I am proficient in this aspect of my practice, I should always take the opportunity to improve upon my skills. I should ensure that I do not become complacent in my approach to treatment with these two individuals in particular; just because I see them on a regular basis for no more than maintenance, symptom relief and general wellbeing treatment, it does not mean that I should not reassess regularly or be vigilant in noticing changes in their functional ability and/or pain.
Also, it is important to regularly ensure than their status of health is the same each week, as any changes on medications should be noted and it should not be assumed that the patient will be notify me of any changes. Often with returning patients of this nature, I tend not to perform an assessment, but how would I be able to record or note any possible findings without a thorough assessment at the start and end of each treatment?
In order to fully maximise my time at the clinic, I would much rather see a more varied range of patients with a wide range of pathologies and injuries, however this is not necessarily realistic of a real live clinic scenario in the world of sports therapy and as such I should try to suggest that these particular patient consider reducing reliance on the clinic and better committing to an exercise based plan (as suggested) to increase time between sessions and eventually manage their symptoms themselves.

The second patient with Scheuermann’s kyphosis has adopted a more exercise based approach, which sometimes does see minimal improvements, however the treatment each session is very much the same.
In order to add a new dimension to my learning and to the treatment that I have been performing on this patient, I attempted to incorporate subscapular deep tissue massage as this had been previously administered to the patient with positive effects. I had never done this before, so with some guidance from the supervisor, I was able to have a go at this for the first time. I was not afraid to explain to the patient that this was my first attempt, but by being honest and up front, the patient was happy to give me feedback as to the sensation, pressure and effectiveness of the treatment. I used his past experience of this as a measure of my ability to correctly target the subscapularis.
I also practiced my technique at performing pectoralis MET exercises, as these have been found to improve forward shoulder posture by increasing pectoralis minor length and treating postural associated neck pain (Laudner, Wenig, Selkow, Williams and Post, 2015; Thomas, Cavallaro, Mani, Bianco and Palma, 2019).
While treating this patient, the supervisor came in to assist and noticed that due to the patient’s excessive hyper kyphosis, while lying prone, his shoulders rested in a rounded position, horizontally adducting bilaterally. It was advised that a towel be placed under the posterior shoulder joint to support this. Although it made sense to add the support due to the way the patient looked, however I wonder if this was the most appropriate intervention; the patient wasn’t asked if this was uncomfortable before adding the support and also as the aim of this particular element of treatment was to stretch the pectoralis muscles and open up the chest space, would having his shoulders in this position have served as a further means of doing so?

Extra Reflections –
Earlier in the term, I noted my desire to improve my note writing, specifically my ability to use abbreviations. I have found that over the last two months, not only has this improved significantly, I am now much quicker and more precise in doing so. This has a positive impact on my ability to move on to my subsequent clients.
In my experience, I am much more thorough and accurate when I write up my notes either during the appointment or soon after; if I am not able to do this, I tend to forget specific details. By being able to efficiently transcribe my notes during the session, I feel more able to manage my time better between patients and ending my clinic session at the end of the evening.
The following are the notes that I inputted into Cliniko and are more condensed and precise compared with earlier in the academic year. For example, in this case;

S
Previous treatment for subscaps – px during Rx, but felt better afterwards. Increased perceived ROM and mobility.

“X” thoracic ETT effective, has requested the same.

Not able to do exercises through holidays, twice max. No foam rolling. Sleeping on futon not normal bed. Px in upper traps and Cx (Lt).

Has been doing strengthening for external rotators and some Tx mobility last few days.

Not been on computer so Px less than before.

O
Full Passive, active and resisted ROM in cx. Slight bilat.restrictions in int. rotation, no Px, otherwise full active, passive, resisted ROM Of shoulders. Slightly restricted R Tx rotation while seated. Observations as before, no change.

A

As before has requested same Rx. Mobs of Tx and costovertebral jts, STM of sub scaps, thoracic mobility, postural taping

R/x
PA mobs 3×60 T4-T10, PA mobs 3×30 costovertebral Jts, passive thoracic mobility rotation, STM of sub scaps, STM of pectoralis major and minor, MET PIR of Pec Major. Have added sleeper stretch to enhance slight bilat.restrictions in shoulder int. rotation 20–30secs x3, 3xweek and thoracic mobility kneeling against wall and opening up chest hold for 20–30secs x 3, 3xweek. Have not progressed other exs as adherence poor over Christmas holidays.
postural “X” taping.

P

Review exs. If adherence good and progress maintained, adapt/progress exs. Particularly upper back strengthening.

Same Rx as today, mobs, METs, taping and passive mobility.

References –

Laudner, K. G., Wenig, M., Selkow, N. M., Williams, J., & Post, E. (2015). Forward shoulder posture in collegiate swimmers: A comparative analysis of muscle-energy techniques. Journal of Athletic Training, 50(11), 1133–1139. https://doi.org/10.4085/1062-6050-50.11.07

Thomas, E., Cavallaro, A. R., Mani, D., Bianco, A., & Palma, A. (2019). The efficacy of muscle energy techniques in symptomatic and asymptomatic subjects: a systematic review. Chiropractic & Manual Therapies, 27(1). https://doi.org/10.1186/s12998-019-0258-7

For the final part of this session, my supervisor and I made time to sit down and discuss our time together and to reflect on my placement with them at the clinic and we reviewed the goals that we set at the beginning of the term.

As I had the opportunity to discuss my time spent here at the clinic, I was able to record the written feedback provided by Katarina, before forwarded this document on to my personal development tutor.
I have inserted the link to a copy of this Declaration of Placement Attendance and Summative Assessment as well as my Pre-Clinical Experience Checklist here:

Declaration of Placement Attendance and Summative Assessment Artemis Grainger

Declaration of Placement Attendance and Summative Assessment p.2 Artemis Grainger

Exmoor Osteopathy – Pre Clinical Experience Induction Checklist Inc. Health and Safety Artemis Clark

I felt that it was important to allow Katarina the chance to complete the feedback form prior to our discussion so that we can provide our own opinions as to our assessment of the placement and use these as a basis for discussion.

At the beginning of the placement, I did not document what I felt were my strengths as I was unsure at this stage in my development as to where these lie.
I did, however make a note of what I hoped to achieve from the placement and periodically reflected on my progress with these.

1. Gain experience identifying joint movements, end feels and enhance my understanding of capsular patterns:
I have been tremendously lucky to have found a placement within which I had a one on one relationship with my supervisor, who allowed me to take a primary role in many of the assessments and treatments. By Katarina being with me throughout many of my treatments, I was able to attain continual feedback, which provided me with huge reassurance as to my own ability and for me, joint end feels and stiffness is something that I felt I needed more guidance with.
I would manually assess joints and soft tissue and look to have my thoughts confirmed; which by the end of my placement, were more often than not similar to Katarina’s and as accurate as I had hoped.
I feel as though I have developed a better understanding of common restriction patterns and through experiencing recurring issues and by getting hands on, I feel more confident in being more specific about where exactly the restrictions are.
I have learnt that Osteopaths especially, need to be specific with which joints are restricted, for example in vertebrae, as they need this knowledge in order to specifically manipulate the restrictions. As manipulations are beyond my scope of treatment, I had to step aside for Katarina to fulfil this element of the treatment, however I was able to play a huge role in identifying the area of restrictions, often requesting that manipulations may be a feasible option and also manipulating the soft tissue surrounding the joint, in preparation for the joint mobilisations.
I found it difficult to see the differences in manipulation technique from where I was standing and I do feel as though I would like to further my understanding as to the mechanisms behind the specific nature of joint manipulations, but for my current level of understanding, I am able to use before and after manual assessments as a guidance as to the effectiveness of this treatment. In each case of a manipulation, I was able to feel the immediate difference from before the soft tissue and joint mobilisations and manipulations.
Patient feedback has also been a key component in ensuring that treatment has been effective and in discovering any reasons for limitations in this. Because of the relaxed atmosphere and rapport with the patients, I have always been able to trust and rely on their feedback, which has proved incredibly useful.

2. Improve Technique: this has happened naturally throughout my time at the clinic; the more patients I was able to treat, the more chances I got to practice and gain more confidence.

3. Develop a relationship with Exmoor Osteopathy: I feel that this is one of the most positive aspects of this placement. Because I conducted my placement so close to my home, where I will hope to build my future career, I feel confident that I will be able to maintain the relationship that we have developed over the past 50hours of placement. I have ensured that I showed commitment, time management, reliability, willingness to learn, enthusiasm and a good professional attitude, all of which I feel I was able to demonstrate for the duration of my placement.
I feel that having this relationship with the clinic will form a fantastic foundation for me to build upon a new client base in the area and with their help and support, instead of a potential rivalry that may have been present.

The keys points from the placement were as follows:
Strengths: clearly explaining exercise rehab to patients, demonstrating and assessing them as they tried to do it.
Very good hands on treatment.
I was really pleased to have received this feedback. I felt as though the exercise and conditioning aspects of my knowledge and understand as well as the practical elements of this were in need of much improvement and unknowingly, over the course of the last term, I have done just this. In fact, from doing these very reflections, I have gained a much better repertoire of exercises for a wide range of injuries, with evidence based rationale.
I was also reassured to know that Katarina has felt as though the practical element of my treatment was good, as this was something I was really hoping to improve and felt as though I had.
This gives me confidence knowing that I am on the right track to developing good technique suited to my own ability, strength and style. Knowing that I can adapt certain positions and treatment techniques, providing it is still effective, has allowed me to feel confidence in my application of my artistic licence.
Being able to “clearly” explain anything to patients requires a good relationship with them, so these elements to practice all intertwine together.

What are the student’s weaknesses?
Artemis initially lacked a bit of confidence when demonstrating her knowledge and hands on skills, however this rapidly grew as the placement went on. I absolutely agree with this comment; I felt as though my confidence was holding me back in the first weeks of the session, due to my lack of trust in my own knowledge and ability, however with the encouragement from Katarina, the patients and with my growing knowledge and experience, I am continuing to grow in confidence although I still have a very long way to go before I feel confidence (or maybe this will never come!).

What area(s) of professional development would you suggest that the student focuses on in the next 12 months?
Finding evidence based treatments for conditions.
I have thoroughly enjoyed this aspect of my degree. I am not always confident in my own knowledge and ability to explain my rationale behind treatment, but with evidence based treatment and plenty of supporting literature behind most of the treatments that I can offer, I am able to confidently apply these. By conducting this research, I have learnt a great deal of different treatment options of which I may not have considered and as such I have developed a greater range of options. I have also developed an interest in the background of musculoskeletal injuries and throughout this year, I have become more academic in my learning, which has surprised me; I always thought I was more hands on. I am now hoping to use my interest in surrounding literature to apply it in my practical application of sports therapy and hope that this will form a basis for a well-rounded sports therapist.

I feel as though I still need to develop my treatment technique further but as I have developed throughout my time in the clinic, I hope to continue to improve and learn the more experience I gain.
I understand that this vocation is a learning platform for continued development and a steep learning curve and will be throughout my career as a sports therapist, with ever changing research and developments and as such I will hope to remain in tune with the latest studies and maintain a professional level of CPD.

Other comments:
Artemis is a very knowledgeable student with a lot of empathy for patients. She connected very well with all of the patient he treated. She will be an asset for anyone she works for, I wish her all the best for the rest of her studies.

What I have learnt from my time at the clinic from a business perspective:
From my time at Exmoor Osteopathy, I have picked up a number of excellent tips on how I may be able to conduct myself as a clinician, including time management, note writing and note management and, arguably most importantly, developing good rapport with the patients.
I thoroughly enjoyed my time in the clinic and that was largely down to the positive and relaxed atmosphere that Katarina had created and the sheer trust and kind rapport that has been built within the clinic between the patients and the Osteopaths.
I would hope to manage a similar environment within my sessions as I feel that patient feedback in optimised when they feel relaxed and cared for and where the patient’s experience and outcome is top priority.
From this placement, I have developed a further interest in the sheer importance of evidence based exercise rehabilitation and, interesting although this is, in my opinion is my weakest area of knowledge and ability, this is what interested me the most. I have seen so many patients walk through the door and receive treatments that only allow for short term, transient effects and who showed an obvious lack of willingness to commit to any form of exercise plan. I feel as though this was an element that was hugely lacking for these individuals, who themselves felt as though age was a long term barrier, to which I quite disagree.
I want to explore the possibilities of creating a clinic whereby functional, every day movements are restored, maximised and pain reduced. I strongly believe, through reading research and from my experiences in the commercial clinic at Marjon University, that exercise treatment is the most effective in most musculoskeletal injuries, either as the only treatment, or in conjunction with other treatments such as STM, ultrasound, taping and stretching and should be formed into the foundation of any rehabilitation plan.
I feel as though I would be able to bring a more exercise based approach to the elderly population of patients in the area in which I live and nearby to the Osteopathy clinic and could potentially form a creative relationship with Exmoor Osteopathy and help to form a team, whereby we compliment each other’s treatment focus.

I am very grateful for my time at the Exmoor Osteopathy Clinic and will look back at this time fondly and will credit this time and Katarina with a huge element of my personal, academic and practical development as a sports therapist.

Running total of hours: 166.5

Patient 1 – ATFL chronic ankle instability
This patient had previously visited this clinic after having sustained a ligament sprain in her right ankle from playing hockey and had this injury treated during the chronic stages, however is not fully able to take part due to the continual presence of pain, feelings of “stiffness” and fear of reinjury, which is commonly associated with a history of ankle sprains (Houston, Hoch and Hoch, 2018). After a thorough assessment of the joint and the patient’s functional ability, it was unclear to me as to how I may continue treatment.
With the goal to achieve full pain free return to play, I felt it important to talk to the patient about their anxieties of reinjury and come up with a solution to restore the player’s confidence in her recovery.
Apart from reviewing her current strengthening rehabilitation plan and ensuring that this is being maintain and adjusting where necessary, I had thought to suggest the use of elastic therapeutic taping, as a means of injury prevention.
After having identified reduced dorsiflexion in her right ankle compared with the contralateral side by way of the knee to wall test (Hoch & McKeon, 2011), which could be associated with altered landing kinematics (Mason-Mackay, Whatman and Reid, 2017), deficits of up to 1cm were established. We performed STM of the triceps surae group and retested to little effect, so performed mobilisations with movement; I posteriorly glided the talus before instructing the patient to bring her knee forward and repeating slowly and controlled for 60 seconds (Loudon et al., 2008; Nisha, Meghan and Pares., 2014). We managed to gain almost symmetrical dorsiflexion from this and as such deduced joint pathology to be the cause.
With this in mind, we prescribed mobilisations with movement for the patient to do at home using a TheraBand when assistance is unavailable.
My rationale behind taping using ETT is evidence based, with a number of studies finding it to be effective by way of enhanced muscle activation, mechanoreception and neuromuscular stimulation by improving proprioception (Miralles et al., 2010), peroneal muscle activation (Fayson, Needle and Kaminski, 2015) and dynamic balance (Lee & Lee, 2016).

ETT has also been found to be effective in improving ankle dorsiflexion immediately after application and so for this reason, coupled with the aforementioned benefit, we are able to take the opportunity to explore the option, even if only as a placebo effect, to apply this tape on the patient’s ankle before training to give her the confidence to play knowing that a clinically proven and evidence based intervention has been applied.

The following is a video demonstrating the application of kinesiotape to support the ATFL and CFL ligaments by means of mechanoreception in the ankle joint and one which I found useful when practicing this application and demonstrating it for athlete’s to apply with ease by themselves before training or competition.

https://www.youtube.com/watch?v=xYQSMwAh_uY

I will be very interested in any follow up appointment with this patient to find out whether this method of taping was effective in this case and whether she is able to continue to play, knowing that we have been able to rule out any significant clinical dysfunction in her ankle and restore faith in her ability to functionally perform; often it is the later than proves to be the major challenge when athlete’s return to play and so reassurance can sometimes be enough.

Patient 2 – This was a follow up appointment requiring a general soft tissue therapy treatment which included cervical soft tissue massage (STM) and mobilisations which I was able to confidently perform, following a routine assessment of stiffness, pain and ROM. With a range of evidence to support the effectiveness of STM (Cho, Lee and Lee, 2017; Ghodrati et al., 2017; Sefton, Yarar, Carpenter and Berry 2011; Sonmezer, Tüzün, Eker and Yüksel, 2018) and mobilisations (Shih et al., 2017; Shum, Tsung and Lee, 2013) I was able to carry out this treatment with clear rationale and understanding of the associated pathological and physiological effects, however I did still try to maintain professionalism and advocate the incorporation of strengthening and stretching exercises into this patient’s plan with the ultimate aim of improving pain, ROM and function (Hajihosseini, Norasteh, Shamsi and Daneshmandi, 2014; M.-K. Kim, Lee and Yoo, 2018; Kotteeswaran, Rekha, and Anandh, 2012; Thigpen, Lynch, Mihalik, Prentice and Padua, 2010) so that the patient can adopt a more active approach to her own pain management.

Patient 3 – This was a follow up appointment for an infant undergoing a series of craniosacral therapy. I had not seen this patient before and of course this is beyond my scope of treatment, however I am becoming increasingly interested in this area of practice.
This clinic is situated in a small town and from knowing plenty of mothers in the area, I have received tremendous feedback about this clinic from hearsay. As I have previously mentioned, I have reserved opinions on this treatment, as I find it hard to gain confidence in holistic approaches that lack full evidence. The town in which the clinic is located also has a wide demographic of people with regards to their social backgrounds; there is not a lack of wealthy parents who are willing to pay for this expensive complementary treatment with little regard of cost, which is initially what I credited the number of patients to. Conversely, it may be assumed that in areas with relatively low socioeconomic composition, there may not be a place for this expensive option.
However, it really surprised me how many mothers took their children to have craniosacral therapy at the clinic, regardless of their socioeconomic status. In such a small town with a close network between the community, hearsay and word of mouth would form a significant foundation of trust to enable mothers to explore this form of treatment. This, to me, shows not only the professionalism of Katarina and Exmoor Osteopathy clinic, but of Craniosacral therapy as an effective treatment and although I have found very little supporting evidence by way of randomised control studies, clinical outcomes reported in literature, personal and clinical experience have proven enough to create a demand for this and even for families who may not be able to afford this treatment, the very fact that they find the means to afford this, suggests it’s worth amongst families.

It was important for Katarina to allow extra time for this session, due to the nature of the patient; more often than not the infants may be sleeping, crying, need changing or feeding or otherwise difficult to manage. Sometimes the session cannot go ahead due to the aforementioned issues, which can be detrimental to income and productivity on the clinic, however rescheduling appointments occur only rarely and are part of the commitment to this area of practice.

Integrity of the clinician is also important when performing such treatments; if the mother returns for follow up treatment but the findings suggest that the infant would not benefit from it, due to the effectiveness in their first two sessions, it would make for integral, professional and perhaps more importantly kind practice to refund them their session costs and advise the parents that treatment is not needed.
It would be within the rights of the clinic to withhold the costs and treat regardless of need as the session had already been booked, but this would not be honest. In the long term and in my opinion, a clinician would gain far more respect and positive feedback from honesty and would more likely see more patients arrive at your clinic from the power of word of mouth.
I have been in the fortunate position to hear plenty of feedback from mothers who have taken their children for this treatment, without them knowing my association with the clinic and with all feedback positive so far, I am confident that the demand for infant complementary treatments is present especially in the area in which I hope to practice.

References – 

Cho, J., Lee, E., & Lee, S. (2017). Upper thoracic spine mobilization and mobility exercise versus upper cervical spine mobilization and stabilization exercise in individuals with forward head posture: A randomized clinical trial. BMC Musculoskeletal Disorders. https://doi.org/10.1186/s12891-017-1889-2

Fayson, S. D., Needle, A. R., & Kaminski, T. W. (2015). The effect of ankle kinesio tape on ankle muscle activity during a drop landing. Journal of Sport Rehabilitation, 24(4), 391–397. https://doi.org/10.1123/jsr.2014-0221

Ghodrati, M., Mosallanezhad, Z., Shati, M., Rastgar Koutenaei, F., Nourbakhsh, M. R., & Noroozi, M. (2017). The Effect of Combination Therapy; Manual Therapy and Exercise, in Patients With Non-Specific Chronic Neck Pain: A Randomized Clinical Trial. Physical Treatments: Specific Physical Therapy Journal, 7(2), 113–121. https://doi.org/10.32598/ptj.7.2.113

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

Hoch, M. C., & McKeon, P. O. (2011). Normative range of weight-bearing lunge test performance asymmetry in healthy adults. Manual Therapy, 16(5), 516–519. https://doi.org/10.1016/j.math.2011.02.012

Houston, M. N., Hoch, J. M., & Hoch, M. C. (2018). College athletes with ankle sprain history exhibit greater Fear-Avoidance Beliefs. Journal of Sport Rehabilitation. https://doi.org/10.1123/jsr.2017-0075

Kim, M.-K., Lee, J. C., & Yoo, K.-T. (2018). The effects of shoulder stabilization exercises and pectoralis minor stretching on balance and maximal shoulder muscle strength of healthy young adults with round shoulder posture. Journal of Physical Therapy Science. https://doi.org/10.1589/jpts.30.373

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.

Lee, S. M., & Lee, J. H. (2016). Effects of ankle eversion taping using kinesiology tape in a patient with ankle inversion sprain. Journal of Physical Therapy Science. https://doi.org/10.1589/jpts.28.708

Loudon, J. K. (Janice K., Swift, M., & Bell, S. (2008). The clinical orthopedic assessment guide. SciTech Book News. https://doi.org/10.1111/j.1440-6055.2007.00596.x

Mason-Mackay, A. R., Whatman, C., & Reid, D. (2017). The effect of reduced ankle dorsiflexion on lower extremity mechanics during landing: A systematic review. Journal of Science and Medicine in Sport, 20(5), 451–458. https://doi.org/10.1016/j.jsams.2015.06.006

Miralles, I., Monterde, S., Montull, S., Salvat, I., Fernández-Ballart, J., & Beceiro, J. (2010). Ankle taping can improve proprioception in healthy volunteers. Foot and Ankle International, 31(12), 1099–1106. https://doi.org/10.3113/FAI.2010.1099

Nisha, K., Meghan, N. A., & Paresh, p. (2014). Efficacy of Weight Bearing Distal Tibiofibular Joint Mobilization with Movement (MWM) in Improving Pain, Dorsiflexion Range and Function in Patients with Post Acute Lateral Ankle Sprain Quick Response Dode. Int j Physiother res.

Sefton, J. E. M., Yarar, C., Carpenter, D. M., & Berry, J. W. (2011). Physiological and clinical changes after therapeutic massage of the neck and shoulders. Manual Therapy. https://doi.org/10.1016/j.math.2011.04.002

Shih, H. S., Chen, S. S., Cheng, S. C., Chang, H. W., Wu, P. R., Yang, J. S., … Tsou, J. Y. (2017). Effects of Kinesio taping and exercise on forward head posture. Journal of Back and Musculoskeletal Rehabilitation. https://doi.org/10.3233/BMR-150346

Shum, G. L., Tsung, B. Y., & Lee, R. Y. (2013). The immediate effect of posteroanterior mobilization on reducing back pain and the stiffness of the lumbar spine. Archives of Physical Medicine and Rehabilitation, 94(4), 673–679.

Sönmezer, E., Tüzün, E. H., Eker, L., & Yüksel, I. (2018). Effectiveness of mobilization therapy for treating cervical myofascial pain syndrome. / Servikal miyofasiyal ağrı sendromunun tedavisinde mobilizasyon tedavisinin etkinliği. Journal of Exercise Therapy & Rehabilitation, 5(1), 25–32. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=sph&AN=130680661&site=ehost-live

Thigpen, C. A., Lynch, S. S., Mihalik, J. P., Prentice, W. E., & Padua, D. (2010). The effects of an exercise intervention on forward head and rounded shoulder postures in elite swimmers. British Journal of Sports Medicine, 44(5), 376–381. https://doi.org/10.1136/bjsm.2009.066837

Running total of hours: 160.5

The first four hours of this session was spent treating patients and for me, this was my final opportunity to deliver effective treatment to two returning patients of whom I have watched progress throughout my 50 hours of placement at the Osteopathy clinic.

Patient 1 – Hockey player groin strain – this patient was a regular at the clinic for maintenance of his non-specific lower back pain, however in this particular appointment, he presented with groin pain, which although he could not remember any associated trauma, is likely down to an acute tear of the adductors during a hockey training session.
This has not stopped him playing, however is had been causing him significant discomfort over the past two weeks.
The aims of this session, as well as the usual requested STM and soft tissue mobilisations and lumbar spine joint mobilisations, were to start introducing strengthening of the adductor muscles in order to help prevent further injury.
I did wonder whether there was any research that may be suggestive of a connection between lower back disability and/or pain and adductor injury.
It is commonly reported that muscular imbalances, such as reduced adductor to abductor strength and weaknesses in the hip flexors are a major risk factor for hip or groin injuries (Quinn, 2014). Although back pain is not specifically mentioned, it could be either associated with, or an influencing factor in the development of hip injury, as delayed activation of the transverse abdominus and core weakness is reported as a risk factor with core muscles working as antagonists to the spinal muscles and as assisting global stabilisers of the body (Quinn, 2014).
Because a risk factor for adductor injury can be weaknesses in core and strength imbalances, this may indicate that the treatment that we have been providing this patient over the course of the past 3 sessions have not adequately addressed the strength component of his conditioning. Adherence has always been a factor with this individual; he has two young children, a busy lifestyle and self-reports his lack of motivation to comply with rehabilitation and his reliance in passive modalities.
I am very careful to make sure that the patients are aware of the importance of rehabilitation and commitment to rehabilitation programs and that in order to fully experience long term adaptations and benefits, they must follow their prescribed program.

With regards to return to play for adductor strain, this type of rehabilitation was beyond the capacity of the session; the exercise element is lacking in this clinic with the absence of a gym equipment or space and the osteopaths focus predominantly on passive management and offer only limited exercise based rehabilitation for the patient to take home.
If I were in my own clinic environment, I would look to incorporate evidence based sessions as well as prescribing a program for this patient to take home. Although this patient was given some ideas of one of two exercises, they were not demonstrated or written down.
I would have tried to spend a significant portion of the session providing the patient with a solid understanding of the importance of strengthening and in order to help motivate and empower him to commit to it, I would make sure that he knew exactly what exercises, how many and how often to do them.
The patient’s ability to perform a program would also serve as a good marker for progression which the patient will be able to observe.
This stage of adductor strain would require more focus on proprioception and functional movements and I would look to incorporate the multimodal treatment program as recommended by Weir et al. (2011) and introduce core stability and eccentric adductor strengthening as recommended by Hölmich, Larsen, Krogsgaard and Gluud (2010), a study focusing on football specific adductor strains; a sport related closely to hockey with regards to turning and cutting movements as well as the need for strong core and lower back strength.
As reported in Hölmich et al. (2010) and later in Belhaj, Meftah, Mahir, Lmidmani and Elfatimi (2016) 5-18% of injuries per year are groin related. With a significant 10% of all groin injuries being groin strains (Belhaj et al., 2016) and 72% of those athletes not returning to play due to their injury, more emphasis may be needed on the prevention of these injuries, rather than relying on post injury treatment alone.
A study by Belhaj et al., (2016) reported a major risk factor for groin injuries as more dominance in abductor muscle strength compared with adductors and as such a program focusing mainly on strengthening this muscle group would be beneficial, in particular, eccentric exercises (Hölmich et al., 2010). The study by Hölmich et al. (1999) derived an effective method of rehabilitation that also involved addressing the other key risk factors for injury; core stability training, lower back strengthening and proprioception training for balance and coordination; this method reportedly increased return to play to 80% (Hölmich et al., 1999).
I would therefore look to incorporate simple exercises initially to help improve core strength, balance and proprioception such instability boards for 5mins, adductor strengthening such as side lying hip adductions (5reps10sets) as recommended in the early program by Hölmich et al. (1999) which has been recently supported by Belhaj et al. (2016) and by Hölmich et al. (2010).

As groin injuries, in particular groin strains, are commonly reported as a major cause of time lost in sport, it has been recommended by Weir et al. (2011) that in order to reduce the time taken for return to play, a more multimodal approach or agility drills working at 30% intensity, gradually increasing this when pain free could be more effective than the earlier derived core stability and adductor program by Hölmich et al. (1999).
Agility drills such as ladder exercises can be incorporated in hockey sessions and it may be useful to advise and educate patients on the importance of these exercises in reducing future groin injuries or rate of reoccurrence.

It is worth considering that in order to clinically measure adductor and abductor imbalances, an isokinetic dynamometer is reportedly a reliable tool and is recommended for lower limb injuries (Belhaj et al., 2016). However, this clinic did not have access to such equipment, however, so in any future occasions, manual muscle testing would suffice (this means was also reportedly used in muscle testing of the lower limb).

Patient 2 – Soft Tissue Massage and mobilisation with manipulations performed by Katarina.
This was another opportunity to practice my techniques within a clinical setting. I am feeling much more confident each time that I am able to perform manual techniques on patients and am able to better understand that mechanism behind these techniques and therefore facilitate and coordinate each movement more efficiently. Even more so, as I have recently suffered from a reoccurrence of acute lower back pain and spasms, therefore I need to be careful not to irritate this.
This patient was morbidly obese and as such, it was particularly important to adopt my best possible technique while performing passive lumbar mobilisations and SI joint mobilisations. At the beginning of my time at Exmoor Osteopathy, I did not naturally get my entire body close enough to the patient in order to effectively handle the patient, but in order to preserve my back, I need to ensure that I got as close to the patient as possible to reduce the force that I needed in order to move him.
With a growing number of obese individuals, reportedly an increase in prevalence by 50% to nearly a third of the world population since 1980 (Chooi, Ding and Magkos, 2019), it is very important for me to maintain great technique and to be mindful of my own posture when delivering treatments.
I was able to ensure that I was efficient but with minimal energy expenditure in the correct posture, something I felt as though I have improved upon over than past sessions.

Patient 3 – Shoulder and neck pain – has recently started playing violin and this has caused extra strain and increased pain in contralateral side. It was suggested that the patient find another means of propping her violin on her neck, as this constant position may be increasing her discomfort.
This patient was otherwise fit and active and was a committed runner. It is important in all cases to take other areas of the body into consideration, rather than just assessing and treating the site of pain or injury as whole.

In this instance, it is important to consider the possibility to altered kinematics in any of the surrounding joints of the neck and shoulder, including the thoracic spine or scapular for example, as the biomechanics here can cause pain or injury lower down the kinetic chain.
As I have previously discussed, the Shoulder Symptom Modification Procedure (Lewis, 2009; Lewis, 2011) is a useful tool in assessing, treating and/or preventing non-specific shoulder pain.
As I am currently revising for my rehabilitation exam, within which has a large focus on exercises for rotator cuff injury, I was really excited to get the opportunity to test this procedure on a live patient and to experience this on an individual and real case.
The first part of the session involved soft tissue therapy, mobilisations and manipulations as part of an ongoing treatment plan for the patient. I was able to devote a portion of end of the session to go through the Shoulder Symptom Modification Procedure (SSMP) by Lewis (2009). After educating the patient about their shoulder position and going through the first stage of the SSMP (Lewis, 2009) by asking her to place two fingers on her sternum and pushing them out with her chest, she was able to visually and physically experience the mechanism of the posterior back muscles in relation to shoulder posture. This did have an impact on her pain, but was not absolute in eliminating her symptoms, so I continued further through the procedure to scapular position, which I was able to measure and modify. In the exercises that she had been doing between the previous treatments, scapular motions may have potentially had an impact on their effectiveness,
From reflecting on this session, I am aware that I looked at the whole posterior shoulder movements as a bilateral motion, opposed to unilateral asymmetry, which is more often than not more significant for shoulder pathology and unilateral pain than general posture pain.
Regardless of not assessing each individual scapular, when I manually mobilised the scapular’s on this patient and asked her to perform a push up while quadruped, she reported change in sensation and ease of motion and was more conscious of maintaining the correct posture while performing the exercises, as well as understanding the need to strengthen the muscles that help to retract and depress the scapular. If I were to see this patient again, I would reassess to identify any asymmetry that may be associated with any pain in her present condition. In future I will look at the kinematics of the shoulder both bilaterally and unilaterally to eliminate any muscle dominance or weakness in both or either side of the lower back and shoulders.

Scapular dyskinesis is the winging or altered rhythm of movement of the scapular and can be diagnosed when there is early elevation or protraction in either one or both of the scapulars during movements such as shoulder flexion or abduction and/or winging, whereby the scapular is posteriorly moved from the posterior thorax from the medial border and inferior angle of the scapular (McClure, Tate, Kareha, Irwin and Zlupko, 2009).
Although this patient was slim and any movements of the shoulder and thoracic muscles were easily observed, I have found it incredibly challenging to observe this in many of the other patients I have treated because of the surrounding soft tissue and musculature, an issue also highlighted in McClure et al., (2009). However a more specific clinical test to identify this arrhythmia or winging more easily, known as the scapular dyskinesis test derived by McClure et al. (2009), may prove useful for me in future assessments.
This simple method involves five repetitions of flexion with weighted dumbbells and five repetitions of abduction with weighted dumbbells and hand position with thumbs up and elbows straight. The weight is determined dependent on body weight with subjects above 68.1kg using 2.3kg and those under using 1.4kg weights.
The patient would need to have clothing removed for their scapular rhythm and winging to be clinically observed. According to the aforementioned study, observation should prove reliable enough to identify any dysfunction and accompanied by the SSMP by Lewis (2009), advocating the elimination of symptoms process, I would hope to be able to adjust any possible dyskinesia by way of manual therapy such as physically mobilisation the scapular to the correct position, taping and other means of passive realignment or by way of strengthening and stretching the associated musculature.
For winging, strengthening the serratus anterior would help to drawn the scapular anteriorly back towards the thorax and in order to reduce early elevation and protraction during movements by increasing the activation and/or strength in the lower and middle trapezius and rhomboid muscles to aid in retraction and depression.

I did not have enough time in this session to consider the use of postural elastic therapeutic taping (ETT), which was unfortunate as not only do I think this would have helped to facilitate the completion of any exercises conducted in the session and at home by way of manual postural alignment and neuromuscular stimulation (Han et al., 2015; Harput, Guney, Toprak, Colakoglu and Baltaci, 2017; Lewis, 2009; Shih et al., 2017), it would have given me the opportunity to gauge whether I found this useful and effective from a clinical perspective on a real case and practice the procedure.
In any aspect of taping for shoulder pain, there is reportedly little supporting evidence of its effectiveness (Mostafavifar, Wertz and Borchers, 2013) and the suggested likelihood of the nature of placebo being a possible explanation for any findings (Poon et al., 2015) limits clinician’s ability to use this treatment with confidence. From the evidence that is available, Harput et al. (2017) found that in asymptomatic subjects who may be at risk of shoulder injury, overhead athletes for example, ETT taping was recommended for prevention of sub acromial impingement syndrome, a condition associated with shoulder position for which both Shih et al. (2017) and Han et al. (2015) found ETT effective. With effective application of this method with tape at 30-40% stretch, Han et al. (2015) was able to rule out the effects of placebo by way of conducting a single blind study, but with the effects suggested to be attributed to neurophysiology as opposed to mechanical adaptions.

References –

Belhaj, K., Meftah, S., Mahir, L., Lmidmani, F., & Elfatimi, A. (2016). Isokinetic imbalance of adductor–abductor hip muscles in professional soccer players with chronic adductor-related groin pain. European Journal of Sport Science. https://doi.org/10.1080/17461391.2016.1164248

Chooi, Y. C., Ding, C., & Magkos, F. (2019). The epidemiology of obesity. Metabolism: Clinical and Experimental. https://doi.org/10.1016/j.metabol.2018.09.005

Han, J. T., Lee, J. H., & Yoon, C. H. (2015). The mechanical effect of kinesiology tape on rounded shoulder posture in seated male workers: A single-blinded randomized controlled pilot study. Physiotherapy Theory and P

Harput, G., Guney, H., Toprak, U., Colakoglu, F., & Baltaci, G. (2017). Acute effects of scapular Kinesio Taping® on shoulder rotator strength, ROM and acromiohumeral distance in asymptomatic overhead athletes. Journal of Sports Medicine and Physical Fitness. https://doi.org/10.23736/S0022-4707.16.06583-X

Hölmich, P., Larsen, K., Krogsgaard, K., & Gluud, C. (2010). Exercise program for prevention of groin pain in football players: A cluster-randomized trial. Scandinavian Journal of Medicine and Science in Sports, 20(6), 814–821. https://doi.org/10.1111/j.1600-0838.2009.00998.x

Hölmich, Per, Uhrskou, P., Ulnits, L., Kanstrup, I. L., Bachmann Nielsen, M., Bjerg, A. M., & Krogsgaarda, K. (1999). Effectiveness of active physical training as treatment for long-standing adductor-related groin pain in athletes: Randomised trial. Lancet. https://doi.org/10.1016/S0140-6736(98)03340-6

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

Lewis, Jeremy S., Wright, C., & Green, A. (2005). Subacromial impingement syndrome: The effect of changing posture on shoulder range of movement. Journal of Orthopaedic and Sports Physical Therapy. https://doi.org/10.2519/jospt.2005.35.2.72

Lewis (2011). Shoulder Symptom Modification Procedure ( SSMP ) V2 Date : Symptomatic movement or posture 1 : Symptomatic movement or posture 2 : (1), 2011.

McClure, P., Tate, A. R., Kareha, S., Irwin, D., & Zlupko, E. (2009). A clinical method for identifying scapular dyskinesis, part 1: Reliability. Journal of Athletic Training. https://doi.org/10.4085/1062-6050-44.2.160

Mostafavifar, M., Wertz, J., & Borchers, J. (2013). A systematic review of the effectiveness of kinesio taping for musculoskeletal injury. Physician and Sportsmedicine. https://doi.org/10.3810/psm.2012.11.1986

Poon, K. Y., Li, S. M., Roper, M. G., Wong, M. K. M., Wong, O., & Cheung, R. T. H. (2015). Kinesiology tape does not facilitate muscle performance: A deceptive controlled trial. Manual Therapy. https://doi.org/10.1016/j.math.2014.07.013

Shih, H. S., Chen, S. S., Cheng, S. C., Chang, H. W., Wu, P. R., Yang, J. S., … Tsou, J. Y. (2017). Effects of Kinesio taping and exercise on forward head posture. Journal of Back and Musculoskeletal Rehabilitation. https://doi.org/10.3233/BMR-150346

Weir, A., Jansen, J. A. C. G., van de Port, I. G. L., Van de Sande, H. B. A., Tol, J. L., & Backx, F. J. G. (2011). Manual or exercise therapy for long-standing adductor-related groin pain: A randomised controlled clinical trial. Manual Therapy. https://doi.org/10.1016/j.math.2010.09.001

Running total of hours 156.5
Patient 1 – Previous history of strain in erector spinae
All assessment of this patient indicated the muscular involvement was most likely. The pain was localised and muscle testing provoked pain with resisted movements and any passive motions unprovocative. No indication of joint pathology and due to the chronic nature of the pain and subjective onset last year, I was confident that this treatment would be strengthening based, with passive modalities such as STM and stretching feasible options.

One of the most important elements to treatment and rehabilitation is the goal of the session and regardless of what stage of injury the patient is in, what they hope the outcome to be, determines the course of treatment and our approach as therapists.
At present, the pain in this patient’s back was low and of minimal irritability, but his anxieties led him to believe that he may not fully enjoy his sport again due to the constant feeling of discomfort. This apprehension and anxiety will only serve to hinder progress and potential exercise adherence and so with some motivation and positive communication, my aim was to encourage this patient to commit to a more regular exercise schedule.
The patient showed little enthusiasm and belief in the effectiveness of strengthening exercises in the treatment of his pain at the beginning of the session, however after taking the time to through each exercise and explaining the rationale behind them, he left the clinic feeling more empowered; the patient commented on his renewed motivation since returning to the clinic.
The exercises that I prescribed included glute bridges with additional resistance bands around the thighs to activate the lateral abductor muscles (Gasibat, Simbak and Bin, 2017), as this patient also presented with weakness here as well as a dull pain in his lateral thigh.

I did not feel comfortable knowing how to test this patient’s source of pain, which is undoubtedly the result of poor anatomy knowledge and have since worked to develop this. I have found the following video incredibly useful in knowing how to individually test each quadricep muscle and other muscles on the lower leg.

https://www.bing.com/videos/search?q=physiotuturs+thigh+muscle+testing&&view=detail&mid=9A296CF7FBA8DE092FDE9A296CF7FBA8DE092FDE&&FORM=VRDGAR&ru=%2Fvideos%2Fsearch%3Fq%3Dphysiotuturs%2520thigh%2520muscle%2520testing%26qs%3Dn%26form%3DQBVDMH%26sp%3D-1%26pq%3Dphysiotuturs%2520thigh%2520muscle%2520testing%26sc%3D0-33%26sk%3D%26cvid%3D3233B1077791449180922BD03212EE4E

This video by the PhysioTutors also helped me to consider a more accurate approach to muscle testing. I have previously thought that muscle testing and grading was a difficult skill acquired from experience, as I have never felt myself an accurate judge of muscular strength, however this video differentiated between each grade with specific and easy to understand guidelines.

https://www.bing.com/videos/search?q=how+to+test+strength+in+quads&&view=detail&mid=DB442CEFB2F2C0293419DB442CEFB2F2C0293419&&FORM=VRDGAR&ru=%2Fvideos%2Fsearch%3Fq%3Dhow%2Bto%2Btest%2Bstrength%2Bin%2Bquads%26FORM%3DHDRSC3

Other exercises included the side plank with hip abduction (Gasibat et al., 2017)and the deadlift squat (Camara et al., 2016).
I was unsure as to whether this patient needed to perform this squat with bent or straight needs and I asked for guidance, however I was able to work out the mechanism in this movement and therefore the rationale between each; deadlifting with bent knees excludes the hamstring in this motion, so in order to isolate the erector spinae alone, the patient should keep their knees bent.

It was also suggested that the patient consider the possibility of using a hexagonal barbell instead of a straight one in order to maintain a more even load throughout, as recommended by Camara et al. (2016) in a study that found differences in outcomes between both the hexagonal and straight barbells when performing a squat; the hexagonal barbell was found to better distribute load throughout the joints compared with the straight bar bell. Although deadlifting with a straight bar is generally good way to increase lumbar strength, in the case of lower back pain, prescribing an exercise which predominantly activates lower back and hamstrings may only aggravate symptoms.

Patient 2 – Achillies Tendonitis Exercises
I had plenty of time before this patient arrived and fortunately the clinic was quiet, so myself and two other students engaged in a conversation on tendinopathies to help us to understand the pathology behind the condition so that we can fully appreciate our treatment subscription.

Fortunately, we had also attended a lecture in recent weeks which focused heavily on the differences between tendonitis, tendinopathy and tendinosis, so I was able to recall some knowledge on this to help enhance my ability to differentiate between the pathologies during the diagnostic process and prescribe the correct rehabilitation. This was especially important in this patient as this patient had left a note on his booking which informed me of his main goals for the session which was to receive an appropriate exercise plan to facilitate his return back to running.

We referred back to the lecture notes from Gary Schum to look to derive an appropriate exercise prescription. Early research by Fahlström, Jonsson, Lorentzon, Alfredson (2003) found that eccentric exercises were useful in reducing pain and improving symptoms in chronic mid portion tendinopathy, as was the case with this patient.
In the presence of symptomatic pain, it is recommended that isometric contractions should be used, as these have been reported as inhibiting pain responses (Naugle, Fillingim and Riley, 2012; Rio et al., 2015), specifically low duration with low to moderate intensity (20-50% contractions).
The benefits of isometric contractions are that they can be performed without the reduction of strength and as found by (Rio et al., 2015) in a study on patella tendinopathy, isometric contractions were effective in reducing pain for up to 45minutes after the exercises.
It is important to differentiate between insertional and mid portion tendinopathies as this would determine the treatment prescription in so much as stretching and exercises must not effect areas that may compress the insertional aspects of the tendon. It may be useful to perform other means of lengthening and stretching of associated musculature, such as the triceps surae group by way of foam rolling or STM.
In this case, the pain was very much localised to the mid portion aspect of his achillies tendon and as such exercises that may increase compression of this area were not excluded and stretching could be performed by this patient, even in the reactive stage.

Recently in my reflections, I delved into the different stages of tendinopathy, however I was not fortunate enough to come across an article by Cook and Purdam (2009) of which I have found extremely useful.

Often in my practice, I am aware of the available research and therefore rationale behind the treatment and rehabilitation, however I am not always able to explain the pathology behind the injury and therefore without this knowledge, it is difficult to rationalise the treatment. Instead, I rely too heavily on research findings are recommendations, without a depth of knowledge as to why this evidence was found.
In this particular case of achillies tendinopathy, I am confident in considering eccentric exercises to aid in the strengthening, but I am unsure as to why.
It is also important to know at which point to start the patients on eccentric strengthening but with more knowledge as to the rationale behind them, I may be able to understand this better.
As reported by Cook and Purdam (2009), load is the main variant in tendon health and in most cases, according to Quinlan, Narici, Reeves and Franchi (2019), appropriate loading of the achillies tendon results in physiological adaptations of the tissue. The theory behind the continuum, as reported by Cook and Purdam (2009) is that varying loads can determine the progression or regression of a tendon pathology.

When the tendon is overloaded acutely it is most likely to be reactive tendinopathy and although some structural changes occur in the matrix, such as collagen deformation, it is unlikely to be observed or relevant at this stage. However, in the case of tendon disrepair, matrix breakdown becomes greater and neovascularisation does start to occur and can be seen on diagnostic imaging (Cook & Purdam, 2009).

NB: the group discussion during clinic today was very useful, as I was not sure exactly what neovascularisation was and as it is relevant to achillies tendinopathy, I am pleased we were able to clarify what this was.

This stage is more the result of chronic overload and would likely be the stage in which this patient is in due to his subjective history. The fact that this patient had been overtraining over the course of many years in spite of severe pain and inflammation would suggest that chronic overload should be considered a probably and likely cause.

I was initially confused by the fact that this patient had rested for the previous year and wondered why this had not had an positive effect on his tendon. It was explained that the chronic overuse was in fact accumulative and that although he had stopped, the damage had already occurred and physiological adaptations would likely have taken effect (such as matrix breakdown and neovascularisation).
it was reassuring to read however that these changes could be reversed with the correct loading program (Cook & Purdam, 2009).

A recent review by Quinlan et al. (2019) was unable to differentiate between concentric or eccentric exercises and could not conclude whether one was more effective than the other however, it was suggested that the use of eccentric exercises for older patients could be useful as it required less perceived effort.

It is reported that loading can have an effect on the tendon up to three days after intense loading and therefore it may be that in order to prevent excessive loading, the patient could ensure a period of at least three days of rest before further loading the tendon as opposed to training on a daily basis (Cook & Purdam, 2009).
If loading is the issue, which it most likely is in reactive tendinopathy it may be recommended that low impact, low elastic training be performed such as cycling or swimming as opposed to activities that require running or jumping mechanisms. Educating the patient on stride length may also be appropriate.

When this patient has visited other professionals, he was recommended to load the tendon, with exercises prescribed which were all predominantly eccentric. I would previously have done the same, as it has been widely reported that this is the most effective treatment. However, now that I am more understanding of the continuum model, I am more aware of the differing nature of the pathology and the need to adapt the rehabilitation accordingly.

Patient 3 – Lower back pain and core stability
This patient presented with generalised and non-specific lower back pain and has requested a STM to treat the symptoms of this. The patient had reportedly tried strengthening programs and other means such as stretching and mobility exercises to help manage his symptoms but to no avail. In all previous appointments where I have managed to find recommended exercises of good feasibility, I have yet to fully appreciate their effectiveness because I am early on in their rehabilitation programs; I have not seen the patient enough times to fully notice any long term improvements.
But, if this patient is now failing to notice and improvements in symptoms in spite of a comprehensive exercise program, as well as reviewing this program and looking for potential reasons for it’s ineffectiveness, for example making an adjustments to his technique, I could look to find an alternative route of treatment. For example core stability.
According to Gordon & Bloxham (2016), although improving lumbar spine and hamstring flexibility reduced chronic lower back pain by 18.5 to 58%, core stability exercises were found to be more effective than stretching. It was also found that core strengthening reduced chronic lower back pain by up to 76.8% whereas muscular strength exercises, although also effective, reduce chronic lower back pain by just 61.1% (Gordon & Bloxham, 2016). A study by Chang, Lin and Lai(2015) reviewed previous research findings on the effectiveness of core exercises and their specific nature, reporting the following as effective with the general pattern of up to two sessions a week for between six to ten weeks.
Trunk exercises while quadruped or otherwise (such as sitting or kneeling but not standing), segmented stabilisation exercises and more dynamic movements such as the cat camel, concentrating on breathing in particular, were all incorporated in these programs.
It was interesting to read the consideration of breathing techniques as I did not take this into account when prescribing this to my patient, yet it is a very important aspect of these exercises.
This may be common sense, but it was also reported that the length of the core stability program was also a factor in its effectiveness, with a three week program proving less effective than an eight week one (Gordon & Bloxham, 2016) and as such I will look to educate future patients in the importance of maintaining their programs beyond their perceived need and beyond as a way of ensuring long term benefits and reducing regression. This patient was now fully aware of the advantages of maintaining an exercise program for longer periods of time and to persevere with this until symptoms may start to reduce (and beyond). Also, I felt that we could add another dimension to the program by way of core stability and as such I incorporated some exercises to enhance this.
Exercises such as the bird dog, bridges and side planks were all prescribed with high volume and repetitions with the aim to improve muscular endurance rather than strength.

Patient 4: STM of lower back, glutes and piriformis release with additional PA of L4/5

Extra Reading and discussion during time between patients:

Core stability in general – is it effective?

In any scenario within my practice, I will look to include core stability exercises in rehabilitation. My rationale behind this is due to the enhanced risks that poor core stability brings to an athletes. De Blaiser et al. (2018) highlights the risk factors in athletic injury of the lower limb, finding that neuromuscular control, core strength, endurance and proprioception all increase the likelihood of injury and that core exercises can be used to either prevent injury or help to facilitate back to play in rehabilitation programs.

In an article by Huxel Bliven and Anderson (2013), a table of core stability exercises was created which includes the specific muscle recruitment and therefore specific areas of strengthening.
I will print this off as a reference guide for me to use in clinic and the findings in this study can be referred to as a means to rationalise the use of these exercises, should this be questioned.
I could not upload the table to this blog as the quality was poor, so please see the following link to the article with reference to p. 520.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3806175/

References –

Camara, K. D., Coburn, J. W., Dunnick, D. D., Brown, L. E., Galpin, A. J., & Costa, P. B. (2016). An examination of muscle activation and power characteristics while performing the deadlift exercise with straight and hexagonal barbells. Journal of Strength and Conditioning Research. https://doi.org/10.1519/JSC.0000000000001352

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

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

De Blaiser, C., Roosen, P., Willems, T., Danneels, L., Bossche, L. Vanden, & De Ridder, R. (2018). Is core stability a risk factor for lower extremity injuries in an athletic population? A systematic review. Physical Therapy in Sport. https://doi.org/10.1016/j.ptsp.2017.08.076

Fahlström, M., Jonsson, P., Lorentzon, R., & Alfredson, H. (2003). Chronic Achilles tendon pain treated with eccentric calf-muscle training. Knee Surgery, Sports Traumatology, Arthroscopy. https://doi.org/10.1007/s00167-003-0418-z

Gasibat, Q., & Simbak, N. Bin. (2017). Modified Rehabilitation Exercises to Strengthen the Gluteal Muscles with a Significant Improvement in the Lower Back Pain. 2(1), 20–24. https://doi.org/10.17758/eirai.f0217730

Gordon, R., & Bloxham, S. (2016). A Systematic Review of the Effects of Exercise and Physical Activity on Non-Specific Chronic Low Back Pain. Healthcare, 4(2), 22. https://doi.org/10.3390/healthcare4020022

Huxel Bliven, K. C., & Anderson, B. E. (2013). Core Stability Training for Injury Prevention. Sports Health. https://doi.org/10.1177/1941738113481200

Naugle, K. M., Fillingim, R. B., & Riley, J. L. (2012). A meta-analytic review of the hypoalgesic effects of exercise. Journal of Pain. https://doi.org/10.1016/j.jpain.2012.09.006

Quinlan, J. I., Narici, M. V, Reeves, N. D., & Franchi, M. V. (2019). Tendon Adaptations to Eccentric Exercise and the Implications for Older Adults. Journal of Functional Morphology and Kinesiology. https://doi.org/10.3390/jfmk4030060

Rio, E., Kidgell, D., Purdam, C., Gaida, J., Moseley, G. L., Pearce, A. J., & Cook, J. (2015). Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. British Journal of Sports Medicine, 49(19), 1277–1283. https://doi.org/10.1136/bjsports-2014-094386

Running total: 151.5

Patient 1 and Patient 2 – both my first and second patients in this session were follow ups from previous weeks who requested soft tissue treatment; the first usually attends the clinic weekly and the second has recently started returning on a fortnightly basis.
These sessions were requests and neither patient had considered the potential for further investigations or alternative treatment options and as such I fulfilled their requests and provided them with their treatment.
It was brought to my attention that the patient had a comprehensive injury history to his hip, which was of interest to me and as such I used the time that I was administering STM to ask about his condition as well ask about his experiences.
The patient had a history of a labral tear and femoral acetabular impingement (FAI) and underwent a hip arthroscopy two years prior to this session.
I had little prior knowledge of acetabulum labral tears or FAI and the management of these within a clinical setting, but did some follow up research to better understand this patient’s current rationale behind his ongoing and recurrent visits to the clinic.
Interestingly, acetabular tears are common and are often seen in young and physically active individuals (Smith, Panchal, Ruberte Thiele and Sekiya, 2011). Due to the recurring nature of this patient’s discomfort and how he is unable to manage this through home rehabilitation, I had wondered whether this was typical in patients with previous labral injuries. Specifically, I was intrigued as to how much surgery and/or a labral tear effected hip stability. In a study by Smith et al. (2011) which set out to test whether labral tears significantly affected hip stability, it was found that although removal of at 2cm of the acetabulum by means of a labrectomy removal results in instability, the presence of labral tears or up to 1cm removal of acetabulum had in fact no effect. This research was only done of a cadaver, however so it does not take into account surrounding muscle activation in the aid of movements and stability and the effects of surgical intervention on these structures.
In this particular case, the patient had an arthroscopy, which is reported as being successful in treating patients who experience pain and reduced function after FAI surgery (Philippon, Briggs, Yen, & Kuppersmith, 2009; Sardana et al., 2015). The labral tear may have been debrided in the same procedure but unfortunately, I did not ask the patient about the full extent of the surgical treatment he had undergone because I did not have enough knowledge at this point to fully understand.
The arthroscopy would have been initially performed to treat the impingement but any other pathology would have been assessed and treated where possible, in the same procedure.
Interestingly, out of a study group of 7,351 subjects who attended a follow up appointment two years post hip arthroscopy, 11.7% ended up needing total hip arthroplasty (THA), of which 3% were under 40 (Schairer et al., 2016). It was also found that on average a THA was performed 16 months post arthroscopy (Philippon et al. 2009).

According to Philippon et al. (2009), restoration of excellent functional ability can be influenced by the patient’s participation in rehabilitation and in this study it is simply recommended that the course of treatment immediately post-surgery ensures the restoration of passive before active movements and then strength training with additional hip pendulum exercises. I do not know if the patient followed a prescribed exercise plan after his surgery but I will discuss this with him during his next appointment as I would be interested to know whether this has impacted on his functional ability now. I have understood from this research the need to be prepared for the prospect of a THA but also I have gathered confidence that a successful outcome is viable and as such I will continue to treat this patient as requested in the hope that a more long term management plan is created or improvements are made.
I learnt from this particular research that in order to determine FAI, the following tests are recommended;
FABERS, Quadrant Test, ROM, specifically flexion, adduction and abduction and both internal and external rotation.

As I wrote about earlier in my reflections, I struggle with time keeping. Unfortunately, I ran out of time at the end of this session and found it difficult to end the conversation with this patient meaning that the session overran into the next.
I believe that much of this patient’s need stems from a psychosocial perspective and that he really would like some company, something he even mentioned earlier in the session.
I am not very comfortable with cutting people short when they are engaging in a conversation with me, especially as I feel like I was providing him with a listening ear for his potential anxieties. However, I know that in order to fulfil all appointments today and maintain structure and professionalism, I needed to wrap up the session. From reflecting on this, although there are circumstances whereby a patient will continue to talk regardless of my influence, I feel that in order to end the session on this, I should look to wind down the conversation earlier.
I do feel as though this has improved over the past 3 months, but I am still looking to consider other strategies, such as the use of body language and physically bringing the conversation or session to a close by slowly tidying up from the session and making my way to the reception.
After having spent many hours observing and working alongside Kat Stenner at the osteopathy clinic, I have been able to pick up on how she addresses this issue and admittedly, sometimes this scenario is unavoidable and in these cases, the patient’s wellbeing really is more important than a schedule and providing an listening ear is more important, however similar strategies such as tidying up and discussing payment starts to effectively channel the conversation to a close but in a polite and subtle manner.

Patient 3 – Follow up for thoracic spine mobility and shoulder pain
This was the third appointment for this patient in the clinic, with this session being his follow up. Unfortunately, as my previous patient was late leaving on this occasion, I had very little time to pre-read this patients notes and thought I could do this while engaging in a follow up conversation, but this was not the case and instead, I found myself having to apologise for not remembering much of this case. I was so sure that my poor memory of his injury and rehabilitation and lack of pre reading was noticed by him and I felt as though I wasn’t giving him the best possible treatment at that time.
I feel as though it is a more personable experience when you are greeted by your practitioner who has obviously either remembered you or have done some pre reading on your case. In my future practice, I will make a point to thoroughly read through previous notes, even if this makes me even later in starting the next appointment. I did apologise to the patient for my forgetfulness and explained about the previous session overrunning but took responsibility for my lack of preparation and as I was able to recall his information eventually, the patient was understanding and we made a joke of it.

As mentioned before, this is the third time that I have seen this patient and although progress has been made, it is slow and the symptoms have returned each time.
I was very excited to be able to incorporate some theory that I learnt from lectures in recent weeks regarding the shoulder as this was most relevant in this case. I feel as though I wish I had been able to apply this knowledge much earlier on in this patient’s rehabilitation, as he may not have needed to return by now because not only would we have treated symptoms but we would have looked at his whole kinetic chain and therefore multidimensions of shoulder and thoracic movements, assessing, diagnosis and subsequently correcting any possible underlying causes of symptoms.

For example, scapular stabilisations, thoracic curvature and humeral head procedure as outlined in the Shoulder Symptom Modification procedure (Lewis, Wright and Green, 2005; Lewis et al., 2009; Lewis, 2011). Using this model I first assessed him thoracic spine, which showed good clinical outcomes and I was able to observe full ROM with no pain or restrictions; this may have been due to his excellent adherence to the rehabilitation for increasing his thoracic mobility over his previous sessions. Instead, I looked at his scapulars only to find them both upwardly rotated which was indicative of weakened serratus anterior and lower traps and/or over active upper traps.
I advised the patient to perform scapular stabilisation exercises against the wall and educated the patient on the best position and how to obtain this. I was confident that the patient was aware of how to correct his scapular positions and our intended outcome and explained the need for these simple closed kinetic chain exercises in order to build endurance of the stabilisation muscles of the scapular before progressing the exercises to more dynamic, isotonic open kinetic exercises which may alter the scapular kinematics; until the patient can maintain stabilisation by way of increased muscular endurance in the right postural muscles such as the lower and middle traps and serratus anterior, more functional motions will be difficult to perform and technique may be compromised.

I suggested that after a short program of wall stabilisation exercises, the patient could progress to doing them on floor and incorporating push ups which a maintained technique. This would provide the patient with a more dynamic approach to his rehabilitation, as he is already an active individual with reasonable levels of fitness.

Patient 4 – Scoliosis follow up
I was really looking forward to seeing this patient again, as I had conducted a great deal of research surrounding this condition. In the previous session I videoed his forward flexion and observed the curvature in this movement, which really fascinated me. I started the session by performing a follow up subjective and objective assessment which was all positive, however when asked to perform the single leg stance, it became apparent that the patient had made no progress in stability or in developing symmetrical strength in his stabilising muscles in his back; he was unable to maintain a steady stance and was significantly wobbly throughout the movement. When I asked the patient about the exercises given to him to improve this, he informed me that he did not do them. Fortunately we did perform a clinical objective measure of the single leg stance and so I was able to explain to the patient, through observation, what the outcomes of his rehabilitation was and as it was obvious to see no improvements in this exercise, I was able to help him to understand the implications in his low adherence. Although I was happy that the patient was performing all other exercises, it was this particular one that would have enabled progression through to more functional, dynamic exercises. However, as the patient was still unable to perform the single leg stance in a stable manner, we could not progress.
I wanted to ensure that the patient was happy with his program, to which he responded positively and merely that he had forgotten to include this particular exercise.
From having researched this condition and from having communicated what I had learnt to the patient, I feel more confident that the he had acquired more knowledge and possibly empowered him a little giving him more hope as to his possibilities to live in less pain.
In future I will make sure that we double check that the patient has a good exercise plan to refer to and to review before they leave to clinic to ensure that they know to complete all exercises.

Because he had progressed well in his thoracic mobility exercises, I did add another exercise to enhance this further but to also look to improve his core stability. This was the bird dog. I used this time to practice coaching this technique and as he was not fully able to perform it at first, I needed to adjust the routine; his coordination was the limiting factor instead of his core strength, so instead of the usual opposite leg and arm at the same time, I regressed this to one movement at a time.

I am looking forward to the next session, where we will look to progress his exercises further and hopefully observe improvements.

Extra time between patients – I used this time to physically perform all of the exercises that I had so far prescribed in my clinic session. Unfortunately I did not have any other students to discuss and practice these with as they were all busy with clients, but I was able to use all of the equipment and have a go. I find explaining exercises very difficult as I usually have only read about them in theory and have no actually tried them out myself. Sometimes manoeuvring myself around the equipment, especially the gym balls is quite a challenge, so demonstrating this to patients seems slightly more difficult than it should be. By taking the time to use the equipment, I am also able to fully appreciate how difficult some exercises can be to master and therefore I can start with more simpler ones for some patients; some are much harder than they look, such as a bilateral hamstring curl, especially for myself who is not used to this type of demand!

References –

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

Lewis, J. S. (2011). Shoulder Symptom Modification Procedure ( SSMP ) V2 Date : Symptomatic movement or posture 1 : Symptomatic movement or posture 2 : (1), 2011.

Lewis, Jeremy S., Wright, C., & Green, A. (2005). Subacromial impingement syndrome: The effect of changing posture on shoulder range of movement. Journal of Orthopaedic and Sports Physical Therapy. https://doi.org/10.2519/jospt.2005.35.2.72

Philippon, M. J., Briggs, K. K., Yen, Y. M., & Kuppersmith, D. A. (2009). Outcomes following hip arthroscopy for femoroacetabular impingement with associated chondrolabral dysfunction: Minimum two-year follow-up. Journal of Bone and Joint Surgery – Series B, 91(1), 16–23. https://doi.org/10.1302/0301-620X.91B1.21329

Sardana, V., Philippon, M. J., De Sa, D., Bedi, A., Ye, L., Simunovic, N., & Ayeni, O. R. (2015). Revision Hip Arthroscopy Indications and Outcomes: A Systematic Review. Arthroscopy – Journal of Arthroscopic and Related Surgery. https://doi.org/10.1016/j.arthro.2015.03.039

Smith, M. V., Panchal, H. B., Ruberte Thiele, R. A., & Sekiya, J. K. (2011). Effect of Acetabular Labrum Tears on Hip Stability and Labral Strain in a Joint Compression Model. American Journal of Sports Medicine. https://doi.org/10.1177/0363546511400981

Running total of hours: 146

Patient 1 – STM and maintenance of fibromyalgia patient
As this was the second time I have encountered this patient, I was much more aware of the presentation and nature of fibromyalgia and as such I felt more confident in delivering a safe and effective treatment that required sensitivity of the patient’s physical and psychological needs.
I knew to communicate wit the patient to gain continued feedback on how the patient was feeling, and although this is usual practice, in this instance, it was even more important to ensure that I was not exasperating the patient’s pain.
I am relatively strong and have always felt the need to perform soft tissue treatment with much force and I often try to apply too much pressure as a result of this, however after a discussion on my practical application of sports massage, Kat suggested that I do not need to use so much pressure, but to take each individual differently; it is more the patient’s tolerance and also need for tissue mobilisation. Instead of just giving a generic sports massage, it is important to feel the individual’s muscle tension and requirements and massage accordingly and this is something I often do not consider. I feel that sometimes I become too complacent when performing soft tissue treatments as I do this on a regular basis and feel proficient at this and as such requires less thought. However, this complacency may be affecting my ability to provide a treatment that is specific to the individual and I should refer back to my rationale of treatment.
This patient benefits hugely from a more gentle approach and with low muscle tone, it is important to apply massage with gentle pressure.

Patient 2 – Scoliosis –
This patient was a regular at the clinic, receiving maintenance and review sessions for the continued treatment for scoliosis.
Earlier in my practical clinic experience, I encountered an individual who was likely to have a slight scoliosis in his spine, however the degree of his curvature probably fell short of a clinical diagnosis of scoliosis (Cheng et al., 2015). This patient was around 15 years older, but had received a clinical diagnosis at a younger age and presented with a greater degree of curvature and a much more obvious curve.
I was able to ask many questions about her experience of the condition and the options that were given to her at a much earlier age than my previous patient.
I found this case especially interesting as the patient had a brother, who had scoliosis to an even greater degree.
As the diagnostic criteria and subsequent treatment for scoliosis is determined by the degree of curvature, it is likely that this patient’s curve did not warrant surgery at the time of assessment when she was thirteen due to the likely low risk of progression for individuals with curvature less than 20 degrees, however her brother’s curve probably did exceed 20 degrees, although the degree of her brother’s curve was unknown to the patient (Trobisch, Suess and Schwab, 2010).
Because of the prospect of a genetic element to this case, the siblings were approached to be involved in research, however this was not materialised and still today, little evidence has been published on the inherent aspect of this condition. However it has been highlighted in a review that genetics probably do present as a possible factor, with up to 70% chance of scoliosis presentation of monozygotic twins (Trobisch et al., 2010). Unfortunately I did not ask the patient if her brother was her identical twin, but he is a relative at least.

The patient found the information that I had learnt from my previous reflections interesting and had given her a small insight into her condition, however I was shocked when she explained that she had never looked into the condition. When talking with patients about research I am careful to cite only reliable sources, so as not to provide false or unreliable information, especially when it may change their course of treatment or rehabilitation focus or motivation. I also make sure that the patient knows to conduct their own research on the subject to further expand their knowledge, because patient education is one of the most important elements to successful rehabilitation adherence in physiotherapy type treatments (Bassett, 2015). I am also careful to ensure that they too learn from reliable sources and remain open minded.

This patient’s brother did undergo the surgery to correct his spine, which provided a successful outcome and the curve is no longer present, however he still experiences the same pain as before of which is of a similar degree to his sister, even though she did not undergo surgery; the only difference between the two individuals is now the aesthetic spinal deformity, which does not seem to cause an issues for the sister.

When taking into account psychological issues that may arise from this abnormal shaped spine and the probability of progression in more obvious curves, it is understandable why some adolescents undergo surgery, but as I have seen in this case, it is not always the most effective in the treatment of pain and the management is usual conservative throughout their lives, hence the continued visits to the clinic.

As I am experiencing with my young male patient in the clinic, I strongly believe that educating the patient on the best exercises to perform at home is the best course of action to develop their own ability to maintain their strength and reduce pain associated with any muscle imbalances. From my understanding of this particular patient and her current rehabilitation plan, the focus is not on exercise or exercise education, but on a repeated cycle of soft tissue manual therapy and although this can be effective in facilitating rehabilitation, it may not provide the patient with long term benefits. If this was my patient in my own setting, I would start to decrease her reliance on the soft tissue passive therapy and keep this to a minimum as per her request, but schedule in regular gym sessions whereby our attentions are on strengthening of the weakened or lengthened areas affected by the curvature.

Patient 3 – Back Pain; considering hypermobility
The final patient due to attend the clinic during this session was unable to make her appointment and therefore I had an hour in which to practice any skills I have learnt or to talk through elements of practice with my supervisor.

Throughout my studies into sports therapy, I have rare has the opportunity to be the patient and as such do not know what it feels like to be on the receiving end of the assessment and when Kat suggested performing an assessment of my back, I took that as a fantastic opportunity to experience what my patients experience, as well as continued discussion on the findings of my lower back assessment.
I learnt a considerable amount from my experience of being the patient. One of the first things I experienced was the nature of physical contact; I find it uncomfortable with physical contact from others and although this was an environment within which I was clearly consenting to a physical assessment, it still came as a shock when Kat put her hands on my lower back and hips and I felt quite uncomfortable. This is what I do every time I see a patient and have to use a hands on approach with my assessments, however I never think to consider constant reassurance and communication as to my actions. I now know that it may just be good practice to reassure my patient of my intentions to place my hands on them and also explain to them in more of a step by step manor.

Patient Overview: Constant lower back ache 3/10 for at least 6 years, previous trauma to back 15 years ago after falling from horse onto a curb.
Recurrent severe lower back spasms that last for up to 10seconds sporadically throughout the day for up to 3 days at it’s worse, improves after 7 days on average.
Often comes on after running and having sat down but this occasion the onset was gradual over one week.
Spasms cause leg muscle weakness and pins and needles when sitting. No indication of root involvement from assessment.
Cannot flex or extent Lx, unable to stand straight and can only lean to right side (Pt slight forward flex and right side flex only comfortable position when walking).
muscle guarding causing severe muscle spasms, particularly in pelvic movements.
At present, Pt noticing improvements but still cannot straighten lower back.
Generally hyper mobile joints, stiffness in Lt SI joint, could not manipulate. Coccyx pain constant; feels like it’s “bruised”.

In this instance, it was hard to perform a thorough assessment as the muscle spasms were so acute and I was apprehensive as to the provocation of these, however an initial assessment ruled out significant nerve root or discogenic involvement as this point, but anatomical abnormalities in the alignment of the vertebrae were noted; significant in this instance or not, some spinous processes protruded more than others. In the absence of other findings or observations, it was suggested that the joint laxity could be a area to consider in the pain element of my injury and as such I researched this.

Hypermobility, prevalent in around 3% of the population, is a condition that can present itself as joint pain, joint laxity and skin changes and is caused by the hyper extensive mechanics of the musckoloskeletal connective tissue (Kumar & Lenert, 2017).
The causes of hypermobility are disputed and under reported, with suggestions of genetics and environmental factors all being considered; gene mutations can be found in up to 10% of those presenting with hypermobility as reported by Kumar and Lenert (2017) with biomechanics and proprioception also thought to be associated with the condition.
Whether hypermobility disrupts posture and/or altered gait, often patients seek treatment because of this and as such hypermobility is then found.
However, although joint mobility is common, the condition of hypermobility is only characterised when pain is present and of those with joint mobility, only 3.3% experience associated pain (making up that 3% of the population) (Kumar & Lenert, 2017).

There is currently a wide catalogue of evidence to suggest the link between hypermobility and sports injuries, as the laxity and flexibility in the ligaments preventing joint sprains (Nathan, Davies and Swaine, 2018), however the more specific link to lower back pain is less researched with a lack of published evidence and I found it difficult to make a link between the two.
I did manage to come across research that may start to associate the prevalence of hypermobility amongst individuals with myofascial pelvic pain and lower back pain.
and although this was a small study conducted on 19 subjects, the results were still significant and food for thought.

Regardless of whether the back pain is the caused in this instance, the general advice for treatment includes a management program of exercises to strengthen areas of pain or weakness to help maintain or increase joint stability (Kumar & Lenert, 2017) and as previously found, treatment for non-specific back pain is also most commonly treated by strengthening exercises, for example glute bridges and clams for glute max. and med., (Gasibat, Simbak and Bin, 2017) and as such, this is the treatment route most likely to result in the most effective outcome, in the absence of a clear evidence of and/or protocol for the treatment of lower back pain with any possible hypermobility involvement.

Interesting fact one: Joint pain is also known as arthralgia which I did not know.
Interesting fact two: Not related to this particular case but while researching hyper mobility I found out a great deal of interesting information, of which could prove useful in my future practice as a sports therapist. I was surprised to learn from a study by Fagevik Olsén Brunnegård, Sjöström, Biörserud and Kjellby-Wendt (2017) that joint pain where present in subjects due to receive weight loss surgery, specifically in the hands, ankles, shoulders and feet was increased after weight loss compared with the subjects who had surgery but did not present with hypermobility.
although weight loss is always advocated, especially in individuals experiencing joint pain as a result of this, this study perhaps indicates the need for patient education into the controlled manor in which weight loss should occur and the expectations of the outcome. Although this study was not primarily researching the effects of weight loss on hypermobility, it is an insight into the possible implications of the effects of weight and ligament laxity on joint mobility and pain.

References – 

Bassett, S. (2015). Bridging the intention-behaviour gap with behaviour change strategies for physiotherapy rehabilitation non-adherence. New Zealand Journal of Physiotherapy, 43(3), 105–111. https://doi.org/10.15619/nzjp/43.3.05

Cheng, J. C., Castelein, R. M., Chu, W. C., Danielsson, A. J., Dobbs, M. B., Grivas, T. B., … Burwell, R. G. (2015). Adolescent idiopathic scoliosis. Nature Reviews Disease Primers. https://doi.org/10.1038/nrdp.2015.30

Fagevik Olsén, M., Brunnegård, S., Sjöström, S., Biörserud, C., & Kjellby-Wendt, G. (2017). Increased joint pain after massive weight loss: is there an association with joint hypermobility? Surgery for Obesity and Related Diseases. https://doi.org/10.1016/j.soard.2017.01.018

Gasibat, Q., & Simbak, N. Bin. (2017). Modified Rehabilitation Exercises to Strengthen the Gluteal Muscles with a Significant Improvement in the Lower Back Pain. 2(1), 20–24. https://doi.org/10.17758/eirai.f0217730

Kumar, B., & Lenert, P. (2017). Joint Hypermobility Syndrome: Recognizing a Commonly Overlooked Cause of Chronic Pain. American Journal of Medicine. https://doi.org/10.1016/j.amjmed.2017.02.013

Nathan, J. A., Davies, K., & Swaine, I. (2018). Hypermobility and sports injury. BMJ Open Sport and Exercise Medicine. https://doi.org/10.1136/bmjsem-2018-000366

Trobisch, P., Suess, O., & Schwab, F. (2010). Die idiopathische skoliose. Deutsches Arzteblatt, 107(49), 875–884. https://doi.org/10.3238/arztebl.2010.0875