My Clinical and External Hours Log Sheet for September/October 2019

Here is a scanned copy of my ongoing Clinical Experience Hours sheet. I have not yet had my hours signed by my supervisor at the Exmoor Osteopathy clinic as I will do this at the end of my placement with them in December.
I am posting this on here as a record of my hours. STYH02 – Reflective Journal HOURS LOG SEPTOCT – Artemis Grainger 20051201.docxClini

The mistake at the bottom of the sheet was due to me inputting my hours for the 4th and 5th November into the wrong boxes. I was with Alex Walker at the time who has signed my mistake and resigned for those hours.

Clinic Experience Monday 4th November 2019 –

Patient 1 – Follow up appointment for knee osteoarthritis – exercises and antigravity machine
Patient Overview: returning patient, last session 1 month ago. Most likely cause of medial knee pain is osteoarthritis of the L knee, aggravated by weight and recent increase in running. Previous session included the prescription of exercises to strengthen lateral hip and abductor muscles and well as quadriceps and hamstrings. Exercises included squats, single leg squats and bridges progressing these with a resistance band if pain allows.
This patient has returned to the clinic reporting of improvements pain in every day function and when performing the exercise prescription, even though his adherence to the rehabilitation exercises had been limited. Unfortunately, due to a number of home issues, the patient wasn’t able to complete his exercises daily and within the last week had not been able to complete them at all, however he had noticeable reduction in his pain levels, crediting the few exercises he did do. It is reported that the progression of osteoarthritis of the knee can be caused by muscle weaknesses (Jegu et al., 2014) so with this aim to slow down any progression of OA, reduce pain and improve function, ultimately allowing the patient to return back to running, it is important that he follows this program.
Although he had experienced a reduction of pain and increased movement from doing some of the resistance strengthening, as recommended by Smith et al. (2014) and exercises with resistance bands, as recommended by Vincent & Vincent, (2012), I was unable to progress his exercises this week to introduce more higher intensity isokinetic exercises and incorporate balance training, as found to be effective in reducing pain and increasing function (Takacs et al., 2017) as he was unable to demonstrate good technique or ability in the squats and bridges previously prescribed. It is frustrating as a therapist when an individual does not fully adhere to their rehabilitation so early on in treatment as we are therefore unable to see the potential benefits that it could have on the patient’s progress.
However, as he had returned to the clinic for a follow up appointment, that indicates some level of compliance and willingness for wanting to get better.
This session was designed to help the patient take part in some cardiovascular training which may help facilitate his return participation in running for weight loss and enjoyment purposes. However, I have since found evidence to suggest that weight loss is better achieved through reducing energy ingestion, rather than through exercise alone. A study by Westerterp (2019) on the effects of exercise on weight loss found that exercise alone proved ineffective, possible due to an increase in energy consumption through overcompensating for lost energy after exercise. Reducing energy consumption, therefore was shown as more effective, but that exercise was a useful tool to maintain any weight loss that might have occurred (Westerterp, 2019). I will advise my patient to seek dietary advice on his next visit to the clinic.
The patient opened up to me that he suffers severely from depression and finds this time of the year extremely difficult due to his past commitments to rugby and the corresponding start of the season; he is unable to play rugby now due to previous history of spine injuries. This gave me greater incentive to use the anti-gravity machine, as a way of allowing my patient to experience the joy of running, without overloading his knee in the process and aggravating symptoms and causing pain. There is a great deal of research to provide evidence in the positive physiological effects of exercise and as Osteoarthritis of the knee has been shown to cause depression and anxiety (Vincent & Vincent, 2012), creating an environment whereby the patient can exercise pain free may prove hugely beneficial to both his physical and emotional wellbeing. Exercise has been widely researched and evidence has been reported on the positive effects of exercise on mental health, including decreased anxiety, depression and stress and an increase in psychological functions; Mikkelsen et al. (2017) not only provided evidence for the aforementioned effects but also on the positive effects of exercise on inflammation, whereby decreases in inflammation have been found. This is especially relevant, as OA presents itself as an inflammatory musculoskeletal complaint.

As part of our plan that we derived after the initial consultation with the patient, weight management was a big priority as research has shown the benefits of losing weight on reducing pain in individuals with OA (Atukorala et al., 2016) and in particular at least 10% of body weight, which has been found to reduce pain and improve function (Riddle & Stratford, 2013). However, when I suggested the body composition machine to collect data to use as a clinical marker and monitor progress, his response was lacking enthusiasm and brought about a level of apprehension. Based on what he had already told me about his current and past mental health issues and as it was at a difficult time of year for the patient, I decided not to perform this test for now and re assess at the next session. My patient and I agreed that this information would not be motivational for him at this time and could affect his mental wellbeing.

In order to get my patient exercising again without irritating his knee, I looked into a number of methods of reducing load through reduced weight baring activities such as the Anti- Gravity Treadmill (AGT) and Deep Water Submersion (DWS).
Deep Water Submersion has been reported as having a similar effect of reducing weight baring load as the AGT for injury management and has also been found as an effective method to improve range of movement through resistance exercises (Patil et al., 2013). So in the absence of an AGT, this may have been effective in the early stages of rehabilitation of OA if ROM was compromised. However, as the patient does not have restricted ROM and as DWS in not effective in improving cardiovascular fitness through running due to the water resistance, I didn’t consider this option on this occasion and fully made use of the excellent facilities in the Sports Centre.

I was excited to experience the use of the AGT, as the last patient I had booked in to use this equipment did not arrive for their appointment. I needed to ask for supervisory assistance in order to learn how to use it and provide safe and effective care for my patient.

I was advised by another student to set the AGT to the lowest setting initially, so that the patient can feel the full potential effects of the equipment and gain trust in the concept of running with less gravity and as subsequently apply less loads through his knee. If the last time he ran produced pain, this may have caused apprehension to fully commit to a session on the treadmill, so giving my patient time to understand the mechanisms of the treadmill was important.
The AGT allows for the gradual increase in weight baring load (Liem et al., 2013) while maintaining cardiovascular fitness (Figueroa et al., 2011). Initially, I was able to set the treadmill at 60% of total body weight and increase the load baring weight by 5% every 8 minutes or depending on patient feedback. I wanted to find out at what level my patient could train at without the reproduction of pain. Due to a lack of research on the effects of anti-gravity training on running biomechanics and lower body kinematics, I had initially stressed the importance of reaching as higher load to train pain free as possible so as to mimic usual running loads and I wanted to minimise unnecessary issues such as a change in his running gait. However, Patil et al. (2013) found no differences in running kinematics in their subjects during their research study on the effects of ATT on knee forces.
Moreover, a study by Wang et al. (2011) on a reasonable sample size of 84 individuals with knee OA, compared the outcome of land exercises with aquatic exercises, finding no significant difference in the two programs for the reduction of pain and symptoms. This suggests that training at a lower weight baring load, in this case, may only prove to help build the patient up to normal load without aggravating symptoms, but that this training should only be temporary and inline with his own weight loss and strengthening program.

As it was the first session of cardiovascular training for at least 2 months and because he did not have his inhaler on site, my patient and I both agreed that a 20 minute session would suffice and positively, throughout this session we did not reach a weight baring limit whereby his pain was reproduced. The next session, therefore can look to further load his knee as well as allow for that much needed bought of CV exercise.

Patient 2 – Follow up appointment for sports massage
Patient overview: intense pain during palpation over C7/T1 and pain and “tightness” over upper back, shoulders and neck. Muscle bulk over affected areas and painful AROM of neck and shoulders in most movements. A history of bad news within the past two weeks. Last session of STM helped significantly, pain subsided but returned after another bout of bad news 2 days prior to session. Patient well aware of physiological responses to stress and of her won stressors and has requested a follow up treatment of more STM.

This patient had returned a week after her first session in the clinic for a STM.
My supervisor was also sceptical about the stretching prescription provided by the NHS Physiotherapist and suggested that these were of little use in general musculoskeletal therapy. Stretches are commonly prescribed and are widely incorporated in rehabilitation and treatment programs, so I was surprised by this advice and wanted to expand my own knowledge about stretching and its clinical use.
I am currently conducting my honours project/dissertation on the effects of pectoralis minor stretching on forward shoulder position and hypothesise that a simple four week program of muscle energy technique stretching will increase muscle length and alter postural alignment of the shoulder.
The title of my project is “an investigation into the effects of a 4-week Muscle Energy Technique program on pectoralis minor length in the treatment of forward shoulder posture in woman with young children”.
In writing my proposal, I came across a number of studies reporting the successes of exercise and stretching on improving shoulder and head posture and in the reduction of shoulder and neck pain, however there are few studies that differentiate between the two.
In a study by Lynch et al. (2010) on the effects of an exercise intervention on elite swimmers, found significant differences in forward head posture and shoulder pain, however the intervention program included stretching and strengthening and the positive effects could not be credited to either stretching or strengthening alone or a combination of the two.
Other research, such as that conducted by Hajihosseini et al. (2014), (Kotteeswaran et al., 2012) and M.-K. Kim et al. (2018) to name a few, also found both exercises and strengthening to be effective in reducing forward shoulder posture and reducing pain but also did not distinguish between the two.
The targeted muscle for stretching in all of the aforementioned studies was the pectoralis minor muscle. A study by Rosa et al. (2017) involved 50 participants, 25 with shoulder pain and 25 without, found that after a six weeks home stretching intervention program involving a static stretch against a wall (the same protocol I have often used in clinic), symptomatic subjects experienced a reduction in pain and an enhancement in function.
This stretch used in this study was held for one minute for four repetitions with half a minute rest periods in between (Rosa et al., 2017).
This research showed that stretching increased function and reduced pain but did not increase muscle length, supporting earlier findings by Konrad & Tilp (2014) which showed significant increase in range of motion but no structural muscle changes in 49 randomly assignment subjects.
However, it has been reported that forward shoulder position has been found to be associated with shortened pectoralis length (Finley et al., 2017) and as such it is interesting that any improvements through these stretching and strengthening programs occur, but not because of altered muscle length. A more general report in muscle extensibility has previously highlighted the differences between length and extensibility; after stretching increases in extensibility are found but may not be the result of increased muscle length but of improved sensation (Weppler & Magnusson, 2010).
The research does still encourage the use of these stretches, so I can feel confident in the prescription of these, with ROM and pain being clinical measures, not alterations in pectoralis minor length.

In my research I came across other variations of the pectoralis minor stretch to add to my repertoire for those patients who do not find the wall stretch useful or easy to do, or to add a little variation to their program. Other stretches include

Patient 3 – Follow up appointment for shoulder and thoracic spine stiffness.
Patient overview: follow-up appointment for shoulder pain and thoracic joint stiffness. Really positive feedback from previous session; pain has reduced significantly and almost not present, now full ROM of shoulder and good Lx ROM. Stiffness and restricted ROM in Tx has improved, rotation greatly improved from mobility exercises (sit on couch hands in front, twisting Tx to end range, side to side, or lunging up against wall, knee and arm ) has improved significantly in Lx but has most superiorly into T2/T3.
This patient regularly visits the clinic for STM for maintenance of shoulder pain and ROM.
This patient most recently attended the clinic for STM of shoulders and upper back and mobilisations of Tx. Soft tissue massage of the shoulder has been found to be effective in increasing range of movement of the shoulder and neck (Sefton et al., 2011) and mobilisations have also been found to improve function and reduce pain, with many studies on its effects on the lumbar and cervical spine, for example (Shah & Kage, 2016; Shum et al., 2013) so in theory, this treatment is effective in the short term.
In many of the studies on lumbar spine posterior anterior mobilisations, reduction in muscle activity of the erecter spinae has been reported as the likely reason for the increase in lumbar extension ROM, an example of which is a study by Chesterton & Payton (2017).

This shows the effects of mobilisations in treatment of the lumbar spine, however I have not been able to find any studies on the effects of mobilisations on the thoracic spine and will continue to find out more about the effects and efficacy of this treatment, as we are often using this method within the clinic to help improve thoracic ROM and reduce joint stiffness. From experience working in my external placement at Exmoor Osteopaths, by using objective markers and my improving palpating knowledge of joints I have seen improvements in ROM after mobilisations, however it is hard to be sure whether these improvements are down to the mobilisation treatment itself or the passive movements and general mobility of the patient throughout the session.

It was reassuring to know that the exercises prescribed at the previous session had provided the patient with a home program which was reported as being effective by the patient, as the shoulder has become less painful and his tolerance for higher loads gradually increased. The exercises being performed included resisted isotonic motion for the rotator cuff muscles. The band exercises, which have been shown effective by Mullaney et al. (2017) were given to the patient, specifically for external rotation, as this was slightly reduced at the first session but now back to full range on his follow up.

Overall the patient was very happy with his latest progress, but aware of the short-term nature of the on-the-day treatment he had been attending the clinic for. As he self-reports good adherence to home exercises as previously prescribed and has since experienced the benefits of this, it was by my recommendation that the patient attempts to become less reliant on this massage treatment over time and develop greater strength a function through a program of exercise as opposed to soft tissue treatment.

As well as advising the patient to continue with the shoulder strengthening that has so far been effective, with regards to his thoracic spine, I prescribed the following exercises as demonstrated by this useful video: https://www.youtube.com/watch?v=N3_3cWIuw-A

References –

Atukorala, I., Makovey, J., Lawler, L., Messier, S. P., Bennell, K., & Hunter, D. J. (2016). Is There a Dose-Response Relationship Between Weight Loss and Symptom Improvement in Persons With Knee Osteoarthritis? Arthritis Care and Research. https://doi.org/10.1002/acr.22805

Chesterton, P., & Payton, S. (2017). Effects of spinal mobilizations on lumbar and hamstring ROM and sEMG: A randomised control trial. Physiotherapy Practice and Research. https://doi.org/10.3233/PPR-160081

Figueroa, M. a., Manning, J., & Escamilla, P. (2011). Physiological Responses to the AlterG Anti-Gravity Treadmill. Journal of Applied Science and Technology.

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

Jegu, A. G., Pereira, B., Andant, N., & Coudeyre, E. (2014). Effect of eccentric isokinetic strengthening in the rehabilitation of patients with knee osteoarthritis: Isogo, a randomized trial. Trials. https://doi.org/10.1186/1745-6215-15-106

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

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

Konrad, A., & Tilp, M. (2014). Increased range of motion after static stretching is not due to changes in muscle and tendon structures. Clinical Biomechanics. https://doi.org/10.1016/j.clinbiomech.2014.04.013

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.

Liem, B. C., Truswell, H. J., & Harrast, M. A. (2013). Rehabilitation and return to running after lower limb stress fractures. Current Sports Medicine Reports.

Mikkelsen, K., Stojanovska, L., Polenakovic, M., Bosevski, M., & Apostolopoulos, V. (2017). Exercise and mental health. Maturitas. https://doi.org/10.1016/j.maturitas.2017.09.003

Mullaney, M. J., Perkinson, C., Kremenic, I., Tyler, T. F., Orishimo, K., & Johnson, C. (2017). Emg of Shoulder Muscles During Reactive Isometric Elastic Resistance Exercises. International Journal of Sports Physical Therapy, 12(3), 417–424. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/28593096%0Ahttp://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=PMC5455191

Patil, S., Steklov, N., Bugbee, W. D., Goldberg, T., Colwell, C. W., & D’Lima, D. D. (2013). Anti-gravity treadmills are effective in reducing knee forces. Journal of Orthopaedic Research. https://doi.org/10.1002/jor.22272

Riddle, D. L., & Stratford, P. W. (2013). Body weight changes and corresponding changes in pain and function in persons with symptomatic knee osteoarthritis: A cohort study. Arthritis Care and Research. https://doi.org/10.1002/acr.21692

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

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.2011.04.002https://doi.org/10.1249/JSR.0b013e3182913cbe

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

Shah, S. G., & Kage, V. (2016). Effect of seven sessions of posterior-to-anterior spinal mobilisation versus prone press-ups in non-specific low back pain-randomized clinical trial. Journal of Clinical and Diagnostic Research, 10(3), 10–13. https://doi.org/10.7860/JCDR/2016/15898.7485

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. https://doi.org/10.1016/j.apmr.2012.11.020

Smith, T., Kirby, E., & Davies, L. (2014). A systematic review to determine the optimal type and dosage of land-based exercises for treating knee osteoarthritis. Physical Therapy Reviews. https://doi.org/10.1179/1743288X13Y.0000000108

Takacs, J., Krowchuk, N. M., Garland, S. J., Carpenter, M. G., & Hunt, M. A. (2017). Dynamic Balance Training Improves Physical Function in Individuals With Knee Osteoarthritis: A Pilot Randomized Controlled Trial. Archives of Physical Medicine and Rehabilitation. https://doi.org/10.1016/j.apmr.2017.01.029

Vincent, K. R., & Vincent, H. K. (2012). Resistance Exercise for Knee Osteoarthritis. PM and R. https://doi.org/10.1016/j.pmrj.2012.01.019

Wang, T. J., Lee, S. C., Liang, S. Y., Tung, H. H., Wu, S. F. V., & Lin, Y. P. (2011). Comparing the efficacy of aquatic exercises and land-based exercises for patients with knee osteoarthritis. Journal of Clinical Nursing. https://doi.org/10.1111/j.1365-2702.2010.03675.x

Westerterp, K. R. (2019). Exercise for weight loss. The American Journal of Clinical Nutrition. https://doi.org/10.1093/ajcn/nqz070

Weppler, C. H., & Magnusson, S. P. (2010). Increasing Muscle Extensibility: A Matter of Increasing Length or Modifying Sensation? Physical Therapy, 90(3), 438–449. https://doi.org/10.2522/ptj.20090012

 

External Placement Exmoor Osteopathy Clinic Thursday 31st October 2019 – 4hours

Patient 1 –
Patient overview –
This patient is a regular at the clinic. He is exceptionally tall and in his initial appointment he presented with significant characteristic scoliosis throughout his thoracic and lumbar spine in particular. Over the course of his treatment, the patient has experienced improvements in his scoliosis, but having never seen this clinical presentation before, I was very interested in the long term prognosis of this condition and whether these improvements are short lived and only maintained by regular treatments or whether they could be fully corrected and the need for further treatment diminished.
I have yet been unable to find evidence to support specific musculoskeletal treatments for his condition but from patient feedback and objective markers of spinal curvature angles, obvious improvements have been made in posture, pain and function.
The curvature in the patient’s spine is not noticeable at present unless a thorough observational assessment is performed but at the beginning of his treatment over two years previous, this patient presented with sever abnormalities in his lumbar and thoracic spine.

Patient 2 –
Patient overview – pain in lateral knee and upper 2/3 of peroneal tendons. External rotation of lower leg from knee, osteoarthritis of knee
When performing unilateral hip mobilisations in order to target her SI Joint, I accidentally and unintentionally reproduced her knee pain by the way I was holding onto her foot; while holding her foot with my right hand, I was unknowingly internally rotating and abducting her leg, which closed the lateral aspect of her knee and irritated the cartilage/meniscus in the joint.
My patient kept reporting of pain in her knee but not in her lower back, the location at which I was targeting for the mobilisations, which my supervisor and I worked out to be the result of my mis movement in my right hand. Because my patient had provided me with this feedback, I was able to correct my error but also realise how important it is to control all aspects of my positioning and my hold on my patients. Because I have built a good rapport with my patients, I am able to communicate with them well and work together to find out how I can better my technique.

Because I feel as though I am lacking in a depth of knowledge on exercises and specific muscle strengthening, I wanted to discuss with my supervisor how she was currently progressing this patient with regards to a more long term treatment strategy. The soft tissue massage, mobilisations and manipulations are transient at best in this instance due to the arthritic nature of this patient’s pathology, so the prescription of exercises are paramount to the long term improvements in pain and mobility (Fransen et al., 2015; Vincent & Vincent, 2012).
It has been reported in a review by Vincent and Vincent (2012) that an individual’s biomechanics could be largely responsible for the development of knee OA and in particular, excessive rotation in the tibiofemoral joint and as this patient presented with greater external rotation of this joint in her affected knew, it would therefore be of use to consider the associated muscles. This same study found that in order to improve these adverse biomechanics, resistance training (and in particular with higher loads and fewer repetitions; six to eight repetitions of up to 80% of 1RM), to be most effective in the treatment of osteoarthritis, having boasted a number of benefits such as the increase in knee extensor and flexor strength, pain decrease and functional movements. I wanted to also note that each individual’s symptoms should be an indicator as to the intensity of exercises prescribed and that for the older population, lower intensity exercises should be considered.

My supervisor and I also discussed the Clam exercise, which is often used to strengthen the gluteus muscles and lateral abductors (Macadam et al., 2015; Willcox & Burden, 2013). My supervisor expressed her concern at the difficult nature of the exercise and the dangers of prescribing this exercise to patients who are not familiar with regular strengthening exercises or gym protocol, as there are many ways in which this can potentially be detrimental on muscular strengthening; when the gluteus Medius is not properly engaged, other structures may compensate incorrectly and the wrong muscle groups targeted, causing further imbalances (Willcox & Burden, 2013).
I have, in the past given this exercise readily to my patients, but with this in mind, I will continue to ere on the side of caution, or at least ensure that my patients have a full understanding of what they are trying to achieve when performing this exercise and to ensure that they are using the correct technique. This is important for all exercises; it is important to ask all patients to try the exercises that I demonstrate before leaving the clinic as this will enhance their understanding of the protocols.
I have been able to build on my repertoire of exercises for the gluteus muscles as there are many recent studies testing their effectiveness on improving muscular strength. A review comparing these exercises by Macadam et al. (2015) found that side lying hip abduction (the Clam), side bridge with abduction as well as standing hip abduction with a band as the most effective in activating the glute Medius muscles.
A study by Selkowitz et al., 2013 in which investigated the levels of activation in the gluteus Medius muscle in a number of abductor exercises, found that the Clam was the most effective if the sole purpose is to strengthen this muscle with minimal activation of the tensor-fascia latae (TFL); another hip abductor muscle. These findings were also later supported by another study by Bishop et al. (2018) and suggest that the clam is a specific exercise and I have not yet found evidence based research to suggest otherwise.
It is, however, beneficial as a therapist to be able to extract from this research that if there is a pathology in the TFL but that the cause maybe as a result from associated abductor tightness, the Clam exercise may prove useful in the treatment process.

Patient 3
Patient overview – This patient is an individual who returns regularly to this clinic, presenting with a number of non-specific muscular imbalances, pain and weakness as well as joint stiffness and other such pathology due to a lifetime of high impact activities and an extensive past history of traumatic injury.
Throughout her time visiting the clinic, she has experienced a significant increase in mobility and a reduction of pain, however there are still obvious deficits in ROM.
This case was interesting because she reported having fibromyalgia, a condition that I know very little about, yet can affect up to 4% of the population . I took the opportunity to better understand how this may influence the way clinicians both treat and interact with their patients.
Fibromyalgia (FM) is a condition characterised by the presence of nonlocalized musculoskeletal pain which is often present alongside other unexplained conditions associated with sleep, memory, fatigue and mood (Clauw, 2015). Fibromyalgia is thought to be caused by the over sensitivity of pain reception by way of allodynia, the increased sensitivity to pain stimuli and hyperalgesia, the heightening response to this stimuli, when compared with the general population (Clauw, 2015).
The treatment for this patient required a more holistic approach and a greater awareness of how pain is tolerated by the individual. Initially, I was applying too much pressure when performing soft tissue massage over the patient’s gluteal muscles. This area is often tender in patients, but with a heightened pain response due to FM, it is important to continually communicate with the patient to ensure that the pain is manageable and that the patient is comfortable.
Although there is a distinct lack of evidence on the effects of soft tissue massage on the treatment of fibromyalgia, a systematic review by Yuan et al. (2015) found myofascial release to be effective in reducing pain, depression and anxiety in immediate, short and long term follow ups and most other forms of massage, with the exception of Swedish massage, had a beneficial effect on symptoms.
As our patient self-reported higher levels of anxiety over the past few weeks due to a number of issues at home, a treatment of soft tissue massage would also have proved beneficial in reducing the physiological symptoms of stress. For example, a study by Bost and Wallis. (2006) in which found massage to be beneficial on an individual’s wellbeing and reduce levels of stress; the stress levels of 60 nursing subjects were reduced after receiving a 15minute massage therapy treatment once a week over a five week period.
Psychological benefits were also discussed in a study by (Poppendieck et al., 2016) investigating soft tissue massage on athletic recovery and it was proposed that although limited, there is qualitative evidence to show that massage treatment does help enhance an athlete’s perception of improvements if nothing else, which is arguably enough to justify its use within clinic, in combination of corrective and strengthening exercises.

I was confident in this treatment modality with our patient , especially when combined with additional mobility exercises and a continued strengthening exercise to take home and her positive feedback from previous sessions.

Busch et al., (2011) reported that exercise, particularly strength training and aerobic exercise has been found to improve symptoms of fibromyalgia and fitness capacity and improve quality of life. Recent research, such as that conducted by Andrade et al. (2017) also found benefits of strength training, stating it as safe and effective in reducing pain and improving sleep quality and as such is recommended in the treatment of fibromyalgia. However, the presence of pain often acts as a barrier to physical activity and as such adherence rates are low. Furthermore, females with the conditions have been reported as being less active than those of the same age but without the condition (Busch et al., 2011).. With this in mind, it was important to tailor a program that our patient will be more likely to adhere to. It may be an option to introduce more home-based exercises that can be performed away from the clinic setting, as this has also been found to improve self-efficacy and likely adherence to exercise, with the overall goal of reducing the need to return to the clinic so often and become more self-reliant in the management of her fibromyalgia symptoms.

Other: During the session I tried to practice my technique at performing soft tissue release of the gluteal muscles while using my other hand to externally and internally rotate the hip while my patient’s knee was flexed. I found it really difficult to synchronise my right and left hand and felt clumsy and not being able to apply anywhere near enough pressure. Because my patient was understanding of my learning process and the need to practice, she allowed me to continue to work on my technique until both she and I were happy that I was creating a similar movement and applying similar desired pressure as my supervisor usually performs.

References –

Andrade, A., Vilarino, G. T., & Bevilacqua, G. G. (2017). What Is the Effect of Strength Training on Pain and Sleep in Patients with Fibromyalgia? American Journal of Physical Medicine and Rehabilitation. https://doi.org/10.1097/PHM.0000000000000782

Bost, N., & Wallis, M. (2006). The effectiveness of a 15 minute weekly massage in reducing physical and psychological stress in nurses. Australian Journal of Advanced Nursing.

Busch, A. J., Webber, S. C., Brachaniec, M., Bidonde, J., Bello-Haas, V. D., Danyliw, A. D., … Schachter, C. L. (2011). Exercise therapy for fibromyalgia. Current Pain and Headache Reports. https://doi.org/10.1007/s11916-011-0214-2

Clauw, D. J. (2015). Fibromyalgia and related conditions. Mayo Clinic Proceedings. https://doi.org/10.1016/j.mayocp.2015.03.014

Fransen, M., Mcconnell, S., Harmer, A. R., Van der Esch, M., Simic, M., & Bennell, K. L. (2015). Exercise for osteoarthritis of the knee. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.CD004376.pub3

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.

Poppendieck, W., Wegmann, M., Ferrauti, A., Kellmann, M., Pfeiffer, M., & Meyer, T. (2016). Massage and Performance Recovery: A Meta-Analytical Review. Sports Medicine, 46(2), 183–204. https://doi.org/10.1007/s40279-015-0420-x

Selkowitz, D. M., Beneck, G. J., & Powers, C. M. (2013). Which exercises target the gluteal muscles while minimizing activation of the tensor fascia lata? Electromyographic assessment using fine-wire electrodes. Journal of Orthopaedic and Sports Physical Therapy. https://doi.org/10.2519/jospt.2013.4116

Vincent, K. R., & Vincent, H. K. (2012). Resistance Exercise for Knee Osteoarthritis. PM and R. https://doi.org/10.1016/j.pmrj.2012.01.019

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

Yuan, S. L. K., Matsutani, L. A., & Marques, A. P. (2015). Effectiveness of different styles of massage therapy in fibromyalgia: A systematic review and meta-analysis. Manual Therapy. https://doi.org/10.1016/j.math.2014.09.003

Clinical Experience Tuesday 29th October 2019 – 5 hours

Link

Patient 1 –
Patient Overview: Follow-up Sports Massage Treatment. Has since seen physio who prescribed stretches for severe restrictions in all cervical spine movements and internal rotation of left shoulder.
I have seen this patient 3 times now and each time I have been unable to perform the most appropriate treatment of mobilisations

I was asked to justify my rationale behind continuing the STM treatment with my patient despite the lack of supporting evidence in its effects on ROM, if the pathology is most likely associated with the cervical spine.
As a therapy team, we suspected non-specific neck pain and cervical joint stiffness based on the severity of the patient’s restricted motion and associated end feels as well as surrounding muscle tension (Ingram et al., 2015; Loudon et al., 2008; Riaz et al., 2018).
My supervisor was very keen on encouraging the patient to allow us to perform mobilisations as he was convinced that this was our best course of action.
I did not have a clear physiological rationale as to why I would be happy to continue with STM, especially as we have seen very minimal improvements over the past 2 sessions, however I was doing all that was asked of me from my patient and I was confident that I had fully communicated our concerns about progression and the short term only benefits of STM on her condition.

A randomised, single-blind study by Ghodrati et al., (2017) found soft tissue treatment such as soft tissue release, METs and exercise prescription as effective in increasing range of motion and reducing non-specific neck pain, however a more recent original research has actually suggested that soft tissue mobilisation is not effective in improving range of motion, compared to traditionally prescribed stretching (Kompal et al., 2019) and although there were some improvements, it was not significant and only immediate effects were measured.
Further research is needed to establish whether positive effects were the result of a combination of treatment modalities, or if stretching alone is enough to encourage an increase in ROM.
It is also important to highlight the small participant sample of 24 in the study by Ghodrati et al. (2017), compared with Kompal et al. (2019), in which 50 were used.
Coulter et al. (2018) also suggested that a multimodal of treatment may be more affective in chronic lower back pain and disability than just mobilisations alone.

Riaz et al. (2018) found that both Kaltenborn method of mobilisations and static stretching have been found to increase ROM and reduce pain and this was a study on 44 subjects.
This study used a protocol whereby the patient was in a sitting position and grade three distraction mobilisations were performed for 7-10 seconds. On reading this, I initially jumped at the prospect of an effective mobilisation treatment in seated position, however, it was concluded that this method was not significantly more effective than static stretching; both were effective, improving active range of flexion by 19.8% in stretching and 22% in distraction and increasing extension by 19.5% by stretching and 22% by distraction (Riaz et al., 2018).

Patient 2 –
Patient Overview: Tennis player with rotator cuff weakness, exhibiting pain in resisted bicep flexion and resisted external rotation, with limited internal rotation.
Based on a previous history of possible rotator cuff tendinopathy and the most recent event of a pectoralis strain, a diagnosis of tendinopathy in the bicep tendon was most likely, with additional weakness in the external rotators (the posterior deltoids, infraspinatus and teres minor muscles) which was contributing to some painful movements in the Glenohumeral Joint.
As with any joint in the human body, it is not just one specific type of contraction of one muscles which causes a single plane movement, it is a combination of synergists, contracting simultaneously in multidimensional planes. Trying to isolate the exact cause of pain by identifying the weak muscle, therefore is almost irrelevant as the treatment will be the same; in this particular case, strengthening of the shoulder complex. Because I was able to identify one movement that reproduced the measurable weakness and pain, in this instance flexion and external rotation, I was able to adapt my program accordingly, focusing a little more on these movements. It is important to note how I did not focus on the prime movers of these movements, but the synergists too; treating the movement rather than the muscle.

With that said, I still felt as though my anatomy knowledge of the Glenohumeral Joint was weak and as such I spent time researching this. It is important to understand the origins of muscles to fully understand the movement capability of the joints.

I find this video of great help when visualising the individual muscles of the shoulder, but my primary source of anatomy revision in all aspects of muscles is the Trail Guide to the Body by Biel and Dom (2010), especially when trying to identify and learn the muscles as a group of movers as opposed to just their location.
In order to ensure that I do dedicate enough time for my anatomy revision, I have set aside at least 30minutes a day, focusing on one joint at a time. My plan is as follows:

Monday – Shoulder and Neck
Tuesday – Forearm, Wrist and Hand
Wednesday –Thoracic and Lumbar spine
Thursday – Hip and Upper Leg
Friday – Knee and Lower Leg
Saturday – Ankle and Foot
Sunday – Recap All

I had initially suggested the option of manual therapy by way of soft tissue massage and mobilisations, as this has been found to reduce pain (Desjardins-Charbonneau et al., 2015), however because of the transient effects of this approach and the lack of supporting evidence to suggest its effectiveness in improving function, I was told by my supervisor not to do this and to start strengthening exercises straight away. I hope to find more studies in support of soft tissue treatment and their effectiveness so that I can provide evidence based rationale to my treatment option, as from my experience, patients have been really satisfied with soft tissue treatment as a way of managing pain and mobility symptoms.

When I prescribed this patient with her exercises, I wrote down the number of repetitions and sets on her card. When reviewing what I had written, my supervisor questioned the rationale behind the relatively high repetitions but low sets. I do not have a good basic understanding of how these exercise programs are derived and could not give an evidence based answer.
According to (Ellenbecker & Cools, 2010) fifteen to twenty repetitions have previously been recommended for up to three sets of resistance training exercises as this helps to improve endurance by provoking a fatigue response of the muscles. However, the current activity levels of a patient should be considered; for example, if they are already able to function and continue with their sport, would they need to induce fatigue by high levels of repetitions or would their current activity levels be enough to do this but strength gains be missed? It may be more intuitive, therefore to increase the load and reduce the repetitions in order to maximise the efficiency of the time spent completing their rehabilitation, especially if they have not yet experienced an improvement in symptoms when just playing the sport, without additional strength training.
I have been unable to find evidence based studies to support this idea, but it was reported that lower loads of resistance exercises such as those using resistance bands are more effective than higher loads in certain exercises due to the order in which the muscles are activated; higher loads target the deltoid muscles, for example but to specifically activate the supraspinatus, lower loads should be used (Ellenbecker & Cools, 2010).
This review also recommended that rehabilitation for the rotator cuff muscles should focus on improving strength and ROM and reducing any imbalances between the internal and external rotators of the shoulder, which is particularly relevant in this patient, and then the subsequent introduction of plyometric training in the later stages (Ellenbecker & Cools, 2010).
When reflecting on the exercises I prescribed my patient, I wondered whether I had provided her with a comprehensive enough program, considering her initial functional capacity and level of tennis ability, an important consideration when designing a rehabilitation plan (Kraemer et al., 2009). I will continue to monitor progression of this patient by way of objective markers such as pain levels, onset of pain and internal rotation ROM to know whether the prescribed exercises have been effective and if not, I will adjust accordingly.
The idea of ‘periodisation’ was also mentioned and explained so that I had a basic understanding of the concept to allow me to further my knowledge on this away from the clinic, which I am continuing to do. From what I understand of periodisation, it is a very important aspect of rehabilitation, taking into account time scales of training and competition and adapting workload to reflect this, with current physical activity levels of patients and potential workload being a huge consideration in deriving a rehabilitation program. I have not been able to find enough research on this but I do know that Periodisation has a dedicated lecture coming up and therefore I can start to learn more about this in my STYH03 – Diagnostic Rehabilitation & Injury module.

Patient 3 –
Patient Overview: Plantar fasciitis
This patient was a very active runner who presented with low level discomfort in the lateral aspect of his foot, anterior to his heel by around 2cm.
After a subjective and objective assessment, it was agreed that the most likely diagnosis was plantar fasciitis, based on his sudden increase in running mileage and the characteristics of his symptoms; morning pain and stiffness that eases throughout the day, onset of pain throughout his running activities and site of tenderness being over the heel (Huffer et al., 2017; Lim et al., 2016).

I was really keen to relieve the patient’s symptoms with soft tissue treatment such as deep tissue and trigger point massage therapy of the plantar fascia and stretching and soft tissue massage of the associated muscles such as the calf and hamstrings, as tightness in these muscles have been found to increase the risk of developing plantar fasciitis (Grieve & Palmer, 2016).
However I was quickly informed that this was transient and therefore unnecessary and that I was to prescribe exercises for my patient to take home instead.
The discussion continued in the direction of our treatment integrity. As much as the short term benefits of soft tissue treatment, such as massage and mobilisations can be justified with some evidence of either physiological or psychological effects, the ethics behind this method of treatment is controversial due to the fact that it is just short term; should we as clinicians be advocating a more exercise heavy approach and be less reliant on the hands on methods?
Although I am aware of the beneficial effects of exercises and strengthening programs in the long term outcome of musculoskeletal injuries (Huffer et al., 2017), I also believe that as we have the knowledge and ability to relieve their initial symptoms, if only for a short while, it will provide the patient with a more comprehensive treatment and therefore could enhance their satisfaction and help them to feel more able to carry out their prescribed exercises thereafter by way of reduced pain and increased ROM from the soft tissue treatment.
Similarly to my earlier patient with the rotator cuff pain, in order to ensure that I am able to proceed with a more hands on approach in the clinic in future, I needed more solid rationale in order to present the clinic supervisor with better reasoning, with the hope they will allow me continue with this treatment. I wanted to find if there was any research that might suggest that a more hands on approach could at least increase patient self-efficacy and subsequently enhance adherence to rehabilitation programs.
In a study by Fraser et al. (2018) it was concluded that manual therapy does improve both function and reduces pain in plantar fasciitis and that when combined with mobilisations, exercises and strengthening, it is effective in the treatment of this condition.
I hope to be able to bring the information I have found from this recent and comprehensive systematic review into the clinic should I come across this injury again, so that I can justify my reasons of this more hands on approach.

Patient 4 –
Patient Overview: Follow up Sports Massage Appointment for treatment of upper back and pelvis pain.
In my initial assessment I discussed the level of treatment that this patient had received in the week previous. Because the usual therapist was absent due to illness, I was given this patient last minute, but wanted to maintain as much treatment continuity as possible. Fortunately I based my treatment almost solely on my own assessments, as opposed to relying on her previous notes alone, as I realised towards the end of the session that my follow up notes were those from another patient and that there was a mix up in the system; the patient I was given was not the same as my booked appointment in Cliniko, the booking software system that we use in the clinic. Bizarrely, their names and injury presentation were remarkably similar and therefore I did not pick up on the mistake until very late into the treatment.
This emphasises, not only the need to check basic patient details with the patient on their first arrival, such as their full name, but the need to be thorough in our own follow up assessment. Often it is tempting to only check if anything has changed since previous treatments and rely heavily on past assessments. Regardless of whether the patient is returning for a follow up or attending an initial appointment, if it is the first interaction between the patient and therapist, it is important to treat each treatment as though it is the first so that nothing is missed.
In this particular case, because I did conduct a more thorough assessment of the patient, instead of assuming the reliability of past notes, I feel as though I observed a potential cause to her lower back pain that was not previously recorded.
As with all patients presenting with lower back pain and after the initial range of motion tests, I assessed the patient’s lumbar spine mobility by way of the standing lumbar extension and pelvic tilt (Gondhalekar et al., 2016).
I have since learnt, however that the most accurate test for lumbar instability, as concluded by Ferrari et al. (2015) is the passive extension test with both sensitivity and specificity of 90%.
I wanted to ensure that I was fully able to perform this test in the next instance whereby lumbar spine is suspected as I can be sure of its reliability. I watched some videos of the test being performed to become more familiar with the protocol, one of which can be viewed by the following link:

As recommended by Shum et al. (2013) I performed posterior/anterior mobilisations on the lower spine, around L4/L5 to reduce joint stiffness and subsequent associated pain.

References –

Biel, A., & Dorn, R. (2010). Trail guide to the body: A hands-on guide to locating muscles, bones, and more. Boulder, CO: Books of Discovery.

Coulter, I. D., Crawford, C., Hurwitz, E. L., Vernon, H., Khorsan, R., Suttorp Booth, M., & Herman, P. M. (2018). Manipulation and mobilization for treating chronic low back pain: a systematic review and meta-analysis. Spine Journal, 18(5), 866–879. https://doi.org/10.1016/j.spinee.2018.01.013

Desjardins-Charbonneau, A., Roy, J. S., Dionne, C. E., Frémont, P., Macdermid, J. C., & Desmeules, F. (2015). The efficacy of manual therapy for rotator cuff tendinopathy: A systematic review and meta-analysis. Journal of Orthopaedic and Sports Physical Therapy. https://doi.org/10.2519/jospt.2015.5455

Ellenbecker, T. S., & Cools, A. (2010). Rehabilitation of shoulder impingement syndrome and rotator cuff injuries: An evidence-based review. British Journal of Sports Medicine, 44(5), 319–327. https://doi.org/10.1136/bjsm.2009.058875

Fraser, J. J., Corbett, R., Donner, C., & Hertel, J. (2018). Does manual therapy improve pain and function in patients with plantar fasciitis? A systematic review. Journal of Manual and Manipulative Therapy. https://doi.org/10.1080/10669817.2017.1322736

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

Gondhalekar, G. A., Kumar, S. P., Eapen, C., & Mahale, A. (2016). Reliability and validity of standing back extension test for detecting motor control impairment in subjects with low back pain. Journal of Clinical and Diagnostic Research, 10(1), KC07-KC11. https://doi.org/10.7860/JCDR/2016/14987.7142

Grieve, R., & Palmer, S. (2016). Myofascial trigger point therapy for plantar fasciitis: A feasibility study. Manual Therapy. https://doi.org/10.1016/j.math.2016.05.161

Huffer, D., Hing, W., Newton, R., & Clair, M. (2017). Strength training for plantar fasciitis and the intrinsic foot musculature: A systematic review. Physical Therapy in Sport. https://doi.org/10.1016/j.ptsp.2016.08.008

Ingram, L. A., Rivett, D. A., & Snodgrass, S. J. (2015). Comparison of cervical spine stiffness in individuals with chronic nonspecific neck pain and asymptomatic individuals. Journal of Orthopaedic and Sports Physical Therapy, 45(3), 162–169. https://doi.org/10.2519/jospt.2015.5711

Kompal, R., Jabeen, Z., & Kashif, M. (2019). Comparison between immediate effects of soft tissue mobilization along with stretching exercises and without stretching exercises in patients with mechanical neck pain. Isra Medical Journal, 11(2), 96–100. Retrieved from https://login.ezproxy.endeavour.edu.au:2443/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=136705160&site=eds-live&scope=site

Kraemer, W., Denegar, C., & Flanagan, S. (2009). Recovery from injury in sport: Considerations in the transition from medical care to performance care. Sports Health, 1(5), 392–395. https://doi.org/10.1177/1941738109343156

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

Riaz F, Haider R, Qamar MM, Basharat A, Manzoor A, Rasul A, et al. Effects of static stretching in comparison with Kaltenborn mobilization technique in nonspecific neck pain. BLDE Univ J Health Sci 2018;3:85-8.

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. https://doi.org/10.1016/j.apmr.2012.11.020

Clinic Experience Monday 28th October 2019 – 5hours

Patient 1 –
Patient Overview – Female presented with pain across lower back but more prevalent in left side. History of fall and treatment from physio and osteopaths.
Scans a year ago have revealed normal degenerative changes and was told to strengthen glutes as these were identified as an area of weakness.

From our subjective assessment, it would be understandable to arrive at the option of hip or lower back pathology, with my initial thoughts moving towards a Sacroiliac Joint dysfunction. However during my objective assessment it became apparent early on that the patient’s gluteus maximus on the ipsilateral side to her reported lower back pain was much weaker than the contralateral side.
As the gluteus maximus plays an important role in the stabilisation of the lower back by way of the erecter spinae and thoracolumbar fascia (Buckthorpe et al., 2019), it is reasonable to associate the findings of her weak gluteal muscles with her lower back pain and as such treatment to help strengthen those gluteal muscles are recommended.

A study conducted by Boren et al. (2011) derived an order of gluteal strengthening exercises by measuring EMG in 18 different exercises, ranking them from those with highest maximal volitional isometric contraction (MVIC) to the lowest; with the top exercises of a front plank hip extension recruiting the gluteus maximus at 106% MVIA, compared to the thirteenth ranked exercise of side-lying abduction with reported 51% MVIA. This table is a useful tool for clinicians, as it can be used to determine which exercises are the most appropriate to incorporate for each stage of rehabilitation and which are relevant to the level of each patients ability or adherence.

This patient lives a sedentary lifestyle, which has been reported as being a significant risk factor in developing weakness in the gluteal muscles (Buckthorpe et al., 2019). Due to these currently low activity levels and the sedentary lifestyle of the patient, I took into account her likely adherence to exercises and as such prescribed a simpler program of gluteal squeezes, which were ranked second in the aforementioned table of gluteus maximus exercises with 81% MVIA and also supported with evidence in a study by Lehecka et al. (2019).
Currently and positively, the patient was performing bridges, as instructed by another clinic. These exercises have been supported by a number of studies which found them as effective in enhancing muscle activation and endurance of the stabilizers of the spine (gluteus muscles and the hamstrings) with Boren et al. (2011) coupling this with hip extension and Youdas et al. (2015) adding an unstable surface to increase the exercise effectiveness.

Figure 1 was taken from Buckthorpe et al. (2019) and has provided me with useful visual examples of exercises that have been found to be effective in gluteus muscle strengthening.

It has also been concluded that performing glute bridges, particularly with a resistance band to facilitate hip abduction, increases gluteus maximus muscle activity significantly (Choi et al., 2015) and has therefore been recommended as an exercise to perform for gluteus maximus weakness and particularly in this study, for the treatment of an anteriorly tilted pelvis.
During this session, I did not feel confident when identifying where the muscle weakness was and needed some supervisory assistance. I am still inexperienced in identifying imbalances and perhaps more relevantly, the muscles causing the imbalances and as such I do not tend to consider this approach when carrying out my assessments. As the gluteus maximus is a global stabilizer and the largest muscle in the body, it is commonly susceptible to being a source of weakness and result in muscular imbalances (Buckthorpe et al., 2019). This could result in huge implications on an individual’s kinetic chain and become a significant risk factor of injury, therefore I will hope to make better connections between pain and muscle weaknesses in future assessments by way of enhancing my anatomical knowledge and ability to isolate and identify specific muscles within muscle groups.

Patient 2 and 3 – Non-specific shoulder pain.
My second patient was attending a follow-up appointment with me but had returned to the clinic unhappy with his progress and reporting that he had aggravated his symptoms when following his previously prescribed treatment plan. It was important to discuss the reasons for this set back and understand why this may have happened.
In the previous session, it became apparent that the patient may have limitations in progression to more function bicep movements by way of apprehension rather than physiological symptoms. This patient reported very little in the way of pain and had no clinical signs suggestive of an injury, however he still felt unhappy with his progress.
My patient and I both agreed that my enthusiasm towards his progression was perhaps a little too much and could have been misinterpreted. I wanted to instil confidence in my patient that he was physiologically able to perform bicep exercises, however my patient felt as though I gave him too much confidence which led to him over exercising and pushing himself too far, subsequently causing his pain to return and increase.
It has been previously stated in a review by Podlog et al. (2011) that athletes who are anxious about re injuring themselves when returning back to sport are more likely to re injure themselves and although some individuals may be physiologically ready to play in terms of pain and range of motion, they may need more time to fully appreciate their functional ability and progress in their rehabilitation. Interestingly, this patient seemed to have jumped from high levels of reinjury anxiety to overloading the tissues due to his determination to return to his previous level of activity with my enthusiasm for his progress, possibly being a major contributing factor. A report by Kraemer et al. (2009) recommended that athletes be properly educated on the physiological processes of injury recovery as a way of reducing the risk of overtraining, however due to the anxieties of my patient and reinjury rate, I was apprehensive about explaining this to him in too much depth.
This report also highlighted the need for everyone involved in the rehabilitation process to fully agree on the progression and processes involved in rehabilitation and by me exerting too much confidence on my patient, I may have overridden his natural will to over train (Kraemer et al., 2009). As recommended by (Blanchard & Glasgow, 2014), regression of some exercises in rehabilitation can be needed to ensure that the overall program outcomes are met. With this in mind, at the end of the session, the patient and I both agreed to change the current program, stop certain aggravating exercises (bicep resistance exercises) and introduce these functional progression exercises more gently at a later stage in the program, to prevent any overloading of tissues and take into account the psychological barriers that may be present.
My third patient also presented with shoulder pain, which I treated in a very similar manor to my previous patient, implementing a similar rehabilitation strategy and prescribing similar exercises. This patient, however, was part of the McMillians Cancer Program.
This is the first encounter that I have had with a patient who has had or is undergoing treatment for cancer. At times during the session, I felt as though I did not have enough basic knowledge of the pathology to be able to understand a lot of what he was saying and I felt uncomfortable not being able to fully engage in the conversation.
I know that throughout my career as a sports therapist, I will come across many patients with a wide range of ailments, pathologies and disorders that are well beyond my knowledge capacity and expected scope of understanding. I need to accept that I can engage in a conversation with my patients and maintain empathy for them, even without knowledge or understanding of their condition.
I can expand my knowledge by asking questions when appropriate and in a sensitive manor. By showing interest in their personal experiences, I will hope that they feel listened to.

Patient 4 –
Patient overview – Initial Appointment for lower back pain
There is little evidence documenting the effectiveness of soft tissue massage for the treatment of soft tissue injuries and although a study by Sefton et al. (2011) on neck and shoulder massage found improved cervical ROM in all movements, the study was limiting, having only included sixteen subjects. This study also found only short term effects and anything after this was beyond the scope of the research and are therefore not useful findings in the treatment of chronic issues.
Although in a comprehensive review by Farber & Wieland (2016) involving 3096 participants, whereby soft tissue massage alone has been found to be an ineffective treatment option for more than just short term relief in lower back pain, there were other previous and original studies that have found it to be effective (Kumar et al., 2013) and some that have found massage as useful when used in conjunction with other treatments such as exercises
There may not be enough evidence for the effectiveness of massage alone in the treatment of soft tissues injuries where there is a mechanical cause of the pain and in this case it may be due to his excessive lumbar lordosis and anterior pelvic tilt.
By using massage as a way of increasing muscle temperature and blood flow (Gasibat & Suwehli, 2017), it may be a useful intervention before the movement and mobilisation of the joint; a possible way to reduce muscle guarding and or stiffness.

Mobilisations, however, have also been the subject of conflicting evidence, with some early studies suggesting that posteroanterior mobilisations did not contribute to mechanical adaptations of the lumbar spine (Goodsell et al., 2000), however it has been found to help relieve pain and increase range of motion in a more recent study by Shum et al. (2013).
Similarly to massage, a combination of modalities are recommended by Shah & Kage (2016) in a study concluding that although effective on their own, both posteroanterior mobilisations and prone press up exercises together are effective in reducing lumbar spine pain, improving lumbar extension and function. Coulter et al. (2018) also suggested combining treatments as this review found only moderate evidence of limited effects of mobilisations alone.
I prescribed this patient with a series of exercises to help improve his posture and excessive anterior pelvic tilt. These exercises included glute bridges with a resistance band to encourage isometric hip abduction (Choi et al., 2015) and mobility exercises for his lumbar spine to encourage and increase ROM.
Throughout my time in the clinic, I have seen a number of patients presenting with lower back pain, which is can often associated with, if not caused by an anterior pelvic tilt (Choi et al., 2015).
I am aware of this in my own posture and I too experience that lower back pain as a result, so know the importance of educating individuals about their posture and the need to strengthen their gluteal muscles, however I find it difficult to approach this subject; I have yet to find a subtle, yet informative way to tell a patient that they “stick their bottoms out”. I am sensitive to the nature of this subject and the implications that this may have on an individual’s self-esteem, due to common societal opinion but from research, for example by (Kim et al., 2015) on 88 students, exercises were found to correct postural malalignments and subsequent pain in shoulders, mid back and lower back.

References – 

Blanchard, S., & Glasgow, P. (2014). A theoretical model to describe progressions and regressions for exercise rehabilitation. Physical Therapy in Sport, 15(3), 131–135. https://doi.org/10.1016/j.ptsp.2014.05.001

Buckthorpe, M., Stride, M., & Villa, F. Della. (2019). Assessing and Treating Gluteus Maximus Weakness – a Clinical Commentary. International Journal of Sports Physical Therapy, 14(4), 655–669. https://doi.org/10.26603/ijspt20190655

Boren, K., Conrey, C., Coguic, J. Le, Paprocki, L., & Voight, M. (2011). Ijspt-06-206. 6(3), 206–223.

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

Coulter, I. D., Crawford, C., Hurwitz, E. L., Vernon, H., Khorsan, R., Suttorp Booth, M., & Herman, P. M. (2018). Manipulation and mobilization for treating chronic low back pain: a systematic review and meta-analysis. Spine Journal, 18(5), 866–879. https://doi.org/10.1016/j.spinee.2018.01.013

Farber, K., & Wieland, L. S. (2016). Massage for Low-back Pain. Explore. https://doi.org/10.1016/j.explore.2016.02.014

Ingram, L. A., Rivett, D. A., & Snodgrass, S. J. (2015). Comparison of cervical spine stiffness in individuals with chronic nonspecific neck pain and asymptomatic individuals. Journal of Orthopaedic and Sports Physical Therapy, 45(3), 162–169. https://doi.org/10.2519/jospt.2015.5711

Kim, D., Cho, M., Park, Y., & Yang, Y. (2015). Effect of an exercise program for posture correction on musculoskeletal pain. Journal of Physical Therapy Science, 27(6), 1791–1794. https://doi.org/10.1589/jpts.27.1791

Kraemer, W., Denegar, C., & Flanagan, S. (2009). Recovery from injury in sport: Considerations in the transition from medical care to performance care. Sports Health, 1(5), 392–395. https://doi.org/10.1177/1941738109343156

Kumar, S., Beaton, K., & Hughes, T. (2013). The effectiveness of massage therapy for the treatment of nonspecific low back pain: A systematic review of systematic reviews. International Journal of General Medicine. https://doi.org/10.2147/IJGM.S50243

Lehecka, B. J., Turley, J., Stapleton, A., Waits, K., & Zirkle, J. (2019). The effects of gluteal squeezes compared to bilateral bridges on gluteal strength, power, endurance, and girth. PeerJ, 7, e7287. https://doi.org/10.7717/peerj.7287

Gasibat, Q., & Suwehli, W. (2017). Determining the Benefits of Massage Mechanisms: A Review of Literature. Article in Journal of Rehabilitation Sciences, 2(3), 58–67. https://doi.org/10.11648/j.rs.20170203.12

Goodsell, M., Lee, M., & Latimer, J. (2000). Short-term effects of lumbar posteroanterior mobilization in individuals with low-back pain. Journal of Manipulative and Physiological Therapeutics, 23(5), 332–342. https://doi.org/10.1067/mmt.2000.106867

Podlog, L., Dimmock, J., & Miller, J. (2011). A review of return to sport concerns following injury rehabilitation: Practitioner strategies for enhancing recovery outcomes. Physical Therapy in Sport, 12(1), 36–42. https://doi.org/10.1016/j.ptsp.2010.07.005

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

Shah, S. G., & Kage, V. (2016). Effect of seven sessions of posterior-to-anterior spinal mobilisation versus prone press-ups in non-specific low back pain-randomized clinical trial. Journal of Clinical and Diagnostic Research, 10(3), 10–13. https://doi.org/10.7860/JCDR/2016/15898.7485

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. https://doi.org/10.1016/j.apmr.2012.11.020

Youdas, J. W., Hartman, J. P., Murphy, B. A., Rundle, A. M., Ugorowski, J. M., & Hollman, J. H. (2015). Magnitudes of muscle activation of spine stabilizers, gluteals, and hamstrings during supine bridge to neutral position. Physiotherapy Theory and Practice. https://doi.org/10.3109/09593985.2015.1010672

External Placement Exmoor Osteopaths Thursday 24th Oct 2019 – 4hours

During this week’s session, I had the opportunity to carry out diagnostic assessments with minimal input from my supervisor.
I have now carried out a number of joint assessments and therefore I have been able to really practice my organisation of procedures. Early on in my clinical experience, I found it difficult to conduct a flowing routine of tests, which resulted in my patient having to move around and continuously change positions. This was apparent with all of my joint testing, however, I am now starting to develop a more efficient method by aiming to test everything in each position. This is especially important with the hip and back, as this requires the patient to perform tests while standing, sitting, walking, lying prone, supine or on either side. As my routine develops through experience, this should hopefully help me to manage my time more efficiently and allow for a more comfortable assessment process for my patients.

For a patient visiting today, I conducted a treatment for chronic neck pain and stiffness which included soft tissue massage and mobilisations (Riaz et al., 2018; Yildirim et al., 2016), with additional manipulations being performed by my supervisor (Grade V manipulations are beyond the scope of my practice).
Many of the patients who come into the clinic are receiving treatment for neck and/or back pain and with many of these patients, joint stiffness has been identified. This is especially apparent in the cervical spine, with research reporting the correlative association between pain and stiffness (Ingram et al., 2015).

In a self-review of my ongoing progress, I looked back at the goals I set myself at the start of my placement.
Goal 1 was to gain experience in identifying joint movements and end feels as well as improving my understanding of capsular patterns. Over the past 4 weeks, I have been able to assess joints with a known pathology, as opposed to asymptomatic joints of my fellow students, which has proved incredibly valuable in my learning. I have been given the task of identifying areas of stiffness and then having this confirmed by my supervisor and I have become more proficient at identifying contralateral differences, but most notably intervertebral joint stiffness specifically in the cervical spine as this is a common issue seen in the many patients attending this clinic. I still have much to learn when identifying exactly what the end feel is indicative of and why, but I will aim to develop this over time. As a first step, I am pleased with my better ability to identify a joint abnormality through movement and touch alone.

My second goal was to improve my technique when manual handling my patients so that I can minimise the risk of injury to myself and allow for a more efficient treatment. At present, I am still finding it hard to perform certain mobilisation or soft tissue techniques as I find the patient to heavy to move around. I am assured by Katrina that she is putting in very little effort when performing the same maneuverers and that I must use my whole body in sync with the patient’s movements, almost as though we are “dancing”. Patient feedback has revealed that I am not able to apply the same pressure or the same type of motion at the moment and therefore I am aware that I still have much room for improvement. I do, however, feel that I am improving with some techniques, such as combined shoulder soft tissue massage with mobilisations and lumbar spine anteroposterior mobilisations and this may be down to the recurring need for this treatment.

My Final goal (3) at the start of my experience at this clinic was to build a good relationship with the clinic osteopaths, Katrina and Ed Stenner. One of the ways in which I feel this could be achieved is through building a good rapport with their patients. I have been able to develop good patient/therapist relationships with the patients and the atmosphere throughout the sessions have been both relaxed and professional. I have felt comfortable asking questions throughout the session, which portrays my enthusiasm to learn and ability to be honest when I am not sure about something. Katrina has been very accommodating and has been able to help with any questions I have had and has been explaining her rationale of treatment to me and has ensured that I remain hands on throughout the sessions.

I am really happy with my progress in this placement and feel that this is a very good opportunity to put everything that I learn in the Marjon Sports clinic into practice. I have also found that this reflective aspect of my placement is a good medium to review my more physical skills as a therapist, as opposed to my knowledge and understanding of treatment rationale, as reviewed in my Marjon clinic reflections.

References –

Ingram, L. A., Rivett, D. A., & Snodgrass, S. J. (2015). Comparison of cervical spine stiffness in individuals with chronic nonspecific neck pain and asymptomatic individuals. Journal of Orthopaedic and Sports Physical Therapy, 45(3), 162–169. https://doi.org/10.2519/jospt.2015.5711

Riaz F, Haider R, Qamar MM, Basharat A, Manzoor A, Rasul A, et al. Effects of static stretching in comparison with Kaltenborn mobilization technique in nonspecific neck pain. BLDE Univ J Health Sci 2018;3:85-8.

Yıldırım, A., Akbaş, A., Dost Sürücü, G., Karabiber, M., Eken Gedik, D., & Aktürk, S. (2016). Miyofasiyal ağrı sendromuna bağlı boyun ağrılı hastalarda mobilizasyon uygulamalarının etkinliği: Randomize bir klinik çalışma. Turkiye Fiziksel Tip ve Rehabilitasyon Dergisi, 62(4), 337–345. https://doi.org/10.5606/tftrd.2016.95777

Clinical Experience Tuesday 22nd October 2019 – 4hours

Patient 1 –
Patient Overview: 8 weeks postop for fractured tib/fib, (has screw and tightrope).
This patient had requested a progression assessment for rehabilitation and for a session of Anti-gravity Treadmill Training (ATT), however unfortunately could not make their scheduled appointment. I made full use of my time in clinic by researching the value of ATT and finding evidence-based articles to support its use. In my research I found that ATT is used as a way of maintaining cardiovascular fitness, but with reduced ground reaction forces (Figueroa et al., 2011) and gradually allowing the increase of weight baring load, which has been reported to theoretically reduce the time taken to return to a normal pattern of loading (Liem et al. 2013).
Due to the nature of the injury and subsequent surgery, immobilisation (and therefore muscle wasting) could become apparent and increase healing times (Henkelmann et al., 2017). Traditional cross-training methods for non or partial weight baring injuries, such as Deep Water Submersion (DWS) have been shown to be effective in reducing ground reaction forces and therefore is a useful method of improving range of movement and incorporating resisted strengthening exercises, however due to the water drag, running or other higher intensity cyclic activities or cardiovascular activities cannot be performed, whereas ATT has been able to address those issues and be an effective rehabilitation option for post op injuries of the lower limb (Patil et al., 2013).
I was disappointed that I couldn’t use this equipment on this occasion but I after having developed understanding of the rationale behind it’s use, I may better appreciate Its value in the clinic and I feel more encouraged to consider this in any future clients who meets the required criteria in their injury management.

Patient 2 –
Medial Epicondylitis is a condition effecting the flexor-pronator tendon and is most likely caused by repetitive forces through flexion and pronation of the forearm (Amin et al., 2015).
When I examined the patient, effusion was noticeable and pain was felt on palpation around the medial condyle with resisted flexion and pronation also reproducing the patient’s pain. All findings, along with a detailed subjective assessment, were suggestive of Medial Epicondylitis (Amin et al., 2015; Fleck et al., 2017).
Non operative treatments are the most recommended treatment option for medial epicondylitis (Fleck et al., 2017) and as such I continued with a conservative treatment plan.
Due to the chronic nature of this case and the characteristics of tendonitis, we administered therapeutic ultrasound. Both therapeutic ultrasound and intensive therapeutic ultrasound have been shown to be effective in reducing pain and enhancing grip strength in individuals with lateral epicondylitis (Shaheen et al., 2019; Slayton et al., 2018). However I was not aware of the benefits of applying kinesiology tape, which has also been recommended for producing the same effects, but to an even greater degree (Shaheen et al., 2019) and therefore in future I will consider kinesiology tape in the treatment of epicondylitis.
I could also have considered the use of mobilisations as this too has been found to increase grip strength and function and decrease pain in lateral epicondylitis (Reyhan et al., 2019).

In order to measure the patient’s progress and the effectiveness of the exercise program that I prescribed, I recorded his grip strength; a method reported as the most reliable objective measure of epicondylitis (Shaheen et al., 2019). I felt confident in prescribing a plan of eccentric strengthening exercises for the associated tendons as these exercises require less perceived demand for greater loads compared with concentric exercises (Quinlan et al., 2019) and therefore the patient could start to strengthen the injured elbow more efficiently and with less perceived load.

Patient 3-
My final patient of the evening presented with symptoms indicative of Patella Femoral Pain Syndrome (PFPS). I have had a number of experiences in performing assessments to diagnose this injury and I felt confident that this was of a similar nature. Once my supervisor and I agreed on a course of action by way of strengthening exercises, I was able to prescribe a comprehensive plan for our patient to perform in the clinic and take with them to do at home.
An example of some exercises have been published in a case report by Welsh et al. (2010), within which core and hip muscles were successfully used in a rehabilitation program to treat a female dancer with PFPS. Exercises such as crab walks with resistance bands, single leg squats with functional movements such as rotation of hip with added resistance were all found effective in this particular case study.
Because of the available research available, such as that by Welsh et al. (2010), I have a good range of exercises in mind to adapt for my patient’s rehabilitation plan, however, I was unsure as to the ‘return to play’ protocol or when running can be resumed again, as this was a major concern for my patient. As the patient had reported improvements in symptoms over the last week from resting, we advised to continue resting for another week before gradually building up miles again to ensure that she does not overload or over train, as this may have been a risk factor for the initial onset of PFPS. I also felt it important to discuss running technique with my patient and in particular, running cadence as increasing this has been found to reduce PFPS (dos Santos et al., 2019) and decrease stride length and hip abductor angle (Hafer et al., 2015). It quickly became apparent that the patient was aware of her self-reported low cadence and as such we discussed ways of improving this, such as the use of a metronome. From the objective, I had noted the internal rotation of the hip when the patient was lying supine on the treatment couch and also exaggerated knee valgus in standing posture. Interestingly, a study by Neal et al. (2018) found that when cadence was increased by 7.5%, PFPS symptoms improved, but most relevantly, hip adduction and internal rotation was reduced, potential explaining the mechanism behind the improvements in symptoms.

It was also interesting to read research by Bonacci et al. (2018) which found that combining an increase in cadence with a more minimalist shoe was effective in reducing joint force and symptoms in individuals with PFPS. This is suggestive of more cushioned shoes being an extrinsic risk factor to this mechanism of injury.

Other –
During the time between patients, when I was not writing up notes I took it upon myself to better understand the upper limb neurodynamic test (ULNT) protocols as I am very unfamiliar with these and have required supervisory assistance when performing these in past sessions.
I have devised a set of help revision cards with the simplified protocols on as a way of a quick help reference during my appointments and as revision of my exams.

Here is a link to the videos and their associated links to relevant research.

References –

Amin, N. H., Kumar, N. S., & Schickendantz, M. S. (2015). Medial epicondylitis: Evaluation and management. Journal of the American Academy of Orthopaedic Surgeons, 23(6), 348–355. https://doi.org/10.5435/JAAOS-D-14-00145

Bonacci, J., Hall, M., Fox, A., Saunders, N., Shipsides, T., & Vicenzino, B. (2018). The influence of cadence and shoes on patellofemoral joint kinetics in runners with patellofemoral pain. Journal of Science and Medicine in Sport. https://doi.org/10.1016/j.jsams.2017.09.593

dos Santos, A. F., Nakagawa, T. H., Serrão, F. V., & Ferber, R. (2019). Patellofemoral joint stress measured across three different running techniques. Gait and Posture. https://doi.org/10.1016/j.gaitpost.2018.11.002

Fleck, K. E., Field, E. D., & Field, L. D. (2017). Lateral and Medial Epicondylitis in the Athlete. Operative Techniques in Sports Medicine, 25(4), 269–278. https://doi.org/10.1053/j.otsm.2017.08.005

Liem, B. C., Truswell, H. J., & Harrast, M. A. (2013). Rehabilitation and return to running after lower limb stress fractures. Current Sports Medicine Reports. https://doi.org/10.1249/JSR.0b013e3182913cbe

Hafer, J. F., Brown, A. M., deMille, P., Hillstrom, H. J., & Garber, C. E. (2015). The effect of a cadence retraining protocol on running biomechanics and efficiency: a pilot study. Journal of Sports Sciences. https://doi.org/10.1080/02640414.2014.962573

Henkelmann, R., Schneider, S., Müller, D., Gahr, R., Josten, C., & Böhme, J. (2017). Outcome of patients after lower limb fracture with partial weight bearing postoperatively treated with or without anti-gravity treadmill (alter G®) during six weeks of rehabilitation – A protocol of a prospective randomized trial. BMC Musculoskeletal Disorders, 18(1), 1–6. https://doi.org/10.1186/s12891-017-1461-0

Neal, B. S., Barton, C. J., Birn-Jeffrey, A., Daley, M., & Morrissey, D. (2018). The effects & mechanisms of increasing running step rate: A feasibility study in a mixed-sex group of runners with patellofemoral pain. Physical Therapy in Sport. https://doi.org/10.1016/j.ptsp.2018.05.018

Patil, S., Steklov, N., Bugbee, W. D., Goldberg, T., Colwell, C. W., & D’Lima, D. D. (2013). Anti-gravity treadmills are effective in reducing knee forces. Journal of Orthopaedic Research. https://doi.org/10.1002/jor.22272

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

Reyhan, A. C., Sindel, D., & Dereli, E. E. (2019). The effects of Mulligan’s mobilization with movement technique in patients with lateral epicondylitis. Journal of Back and Musculoskeletal Rehabilitation. https://doi.org/10.3233/bmr-181135

Shaheen, H., Alarab, A., & S Ahmad, M. (2019). Effectiveness of therapeutic ultrasound and kinesio tape in treatment of tennis elbow. Journal of Novel Physiotherapy and Rehabilitation, 3(1), 025–033. https://doi.org/10.29328/journal.jnpr.1001025

Welsh, C., Hanney, W. J., Podschun, L., & Kolber, M. J. (2010). Rehabilitation of a female dancer with patellofemoral pain syndrome: applying concepts of regional interdependence in practice. North American Journal of Sports Physical Therapy : NAJSPT, 5(2), 85–97. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21589665%0Ahttp://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=PMC2953389

Clinical Experience Monday 21st October 2019 – 6hours

Patient 1 –
Patient overview: medial compartmental knee arthritis
This patient presented with medial knee pain and a self-diagnosis of osteoarthritis (without any other medical opinion or intervention), based on his occupational medical knowledge and a similar occurrence in his contralateral knee 28 months previously. Although the patient was sure of what was causing the pain, I continued with a thorough assessment. With a subjective of normal degenerative changes, previous history of osteoarthritis (OA) and a very recent sudden increase in physical activity with associated pain along the medial joint line, the possibility of meniscus injury or aggravated degenerative pain become apparent, with further testing including Thessaly’s confirming this (Loudon et al., 2008; Picha & Howell, 2018).

During the session, the sensitive topic of weight loss initially instigated by the patient and discussed further and although it is difficult to make this suggestion, it is recommended that individuals with OA have a body mass index (BMI) of less than 25 (Jevsevar, 2013). At present, the patient’s BMI exceeded 30, but we ensured that he fully understood the impact that this has on his joint and in particular his knee pain. Although uncomfortable with the prospect of using the body composition machine in the clinic, he was comfortable with fully adhering to a weight management plan. Further to this, we recommended a program of low impact strengthening exercises of the knee and hip extensors as well as functional movements such as squats, with pain guided progression to single leg squats (Howell et al., 2014; Jevsevar, 2013). Hip exercises were also included as individuals with OA have been found to have deficits in hip muscle strength and strengthening programs have been recommended (Hinman et al., 2010).

When discussing treatment options, I had offered to administer a course of therapeutic ultrasound treatment over the patient’s knee, to which he sceptically declined and I was unable to give him any evidence for it’s use. However, since this session I have been able to find a review, reporting that ultrasound has been found to be effective in the treatment of knee OA by reducing pain and improving physical function (Rutjes et al., 2010; Zhang et al., 2016).

Throughout my treatments, I have found an ongoing issue of poor time management and I often overrun most appointments. This session was my most challenging with regards to keeping to my allotted hour, as I finished 15 minutes late. Although the patient may feel as though they have my full commitment to the outcome of the session (as I do not finish until the patient and I are both confident that the session is fulfilled), this is at the detriment of the next patient and as the patients are booked one after the other, the knock on effect of this continues for every patient. Most significantly, my second patient on this occasion had only her lunch break for her appointment and as such her treatment time was affected.

At present, I am asking many questions of my supervisors so that I can fully understand the diagnostic process and as such many discussions take place. It may be beneficial to my practice if I am able to keep my questions relevant and enough to fulfil the practice only, but then advance on this at the end of clinic, writing down more in-depth questions to ask at a later date.

I hope that as my experience in the clinic continues, I will not only further my knowledge and reduce the need to ask so many questions, but also be able to move through the session more fluidly without the need to pause and request supervisor input. In the meantime, I should try to end the session with at least five minutes to write up clinic notes, but understand that follow up appointments may be needed for the continuation of sessions if not everything can be done in the initial time slot; the diagnostic procedure is very important and therefore cannot be rushed and as such, I must be prepared for this aspect to overrun throughout most of the session and compromise the treatment time, not my next patient’s appointment.

Patient 2 – This patient requested a STM as the final treatment out of three from an occupational referral program. Over the past two treatments with the same therapist, the patient had reported an increase in ROM and a decrease in tension of her upper back and shoulders and as such was very keen for similar treatment. In order to maintain continuity with this patient and provide her with treatment to the same positive effects, I made sure to read her notes thoroughly and ask for feedback throughout the session. I wanted to ensure that the pressure and area of massage was at least as effective to the previous therapist. The patient was pleased with the immediate relief of my treatment and felt satisfied by the end of the session. I also wanted to ensure that I had done everything that I could have for my patient, so that they could maintain this relief after the program stops and so provided the patient with a stretching treatment plan for her pectoralis muscles to add to the exercises she had already been prescribed (Finley et al., 2017; Rosa et al., 2017).

I have since been approached by this patient and was given excellent feedback regarding the treatment; a very satisfied patient.

Patient 3 – This patient did not arrive at his appointment so in order to make full use of my time in clinic, I shadowed another student and assisted in the diagnostic process of a knee injury.
From the subjective and objective assessments, we arrived at the same suggestion of a meniscus injury; most notably because of the painful palpation of the Tibiofemoral joint line, which has a sensitivity of 63-87% (Howell et al., 2014) and a positive Thessaly’s test.

A combination of the Apply’s compression, Grind and McMurray’s test were all negative, but due to their low sensitivity and early stage of this patient’s injury, we wanted to perform another more function test to try and reproduce the pain symptoms and therefore a Thessaly’s was performed, showing a positive result.
When used alone, meniscus tests have low sensitivities, leaving many meniscus injuries undiagnosed. It has been within my usual practice to perform at least three provocation tests, however I did not know whether this improves diagnostic accuracy or not.
From further reading, I found that the Thessaly’s test was not any more valuable to clinicians than other tests for meniscus injury, with a sensitivity of 0.62, a specificity 0.55 and an accuracy of 54% and with McMurray’s, Appley’s and joint line tenderness tests all having similar scores of between 53-55% accuracy (Blyth et al., 2015). Furthermore, a combination of both the joint line test and McMurray’s was not found to be any more accurate than one of the tests alone (Galli et al., 2013).

We advised that our patient should continue to exercise but reduce workload for up to at least 2 weeks, however due to his occupation in the Navy, this was not a possible course of action and therefore we needed to take this into consideration when planning a rehabilitation program. Exercises of muscular endurance rather than stretch could be implemented to continue to increase muscle strength but without overloading the meniscus. A physical therapy program including strengthening of hip musculature, quadriceps and hamstrings, with proprioception was given to the patient as this has been found to reduce knee pain and improve knee function (Howell et al., 2014).

Patient 4 –
This patient presented with foot plantar region pain over the metatarsal phalangeal (MTP) and proximal interphalangeal joints (PIP) of the second and third toes. After a thorough subjective, we discussed the possibility of onset being cased by a sudden change in footwear within slow build up of running mileage and with palpable tender points in our objective, allowing us the probably diagnosis of Metatarsalgia.
From further reading, I have learned that a very important aspect to the assessment of Metatarsalgia is a gait analysis, as it has been reported that up to 90% of injuries are due to biomechanics (Besse, 2016). Although we weren’t able to perform a thorough analysis, his walking gait was observed in which there were no obviously abnormalities and we were able to deduce that footwear may have been the underlying reason behind this condition, with improvements been felt since returning back to his previous footwear.

After performing anterior-posterior and posterior-anterior mobilisations and DTM to relieve some joint stiffness and pain, I prescribed a program of mobility and strengthening exercises for the tibialis posterior muscle and peroneal muscles and also stretches for toe flexors.

Stretching exercises for the Tricep Surae muscle group was also recommended by Besse (2016) as shortened gastrocnemius muscles have been found to increase the risk of equinus deformity and subsequently metatarsalgia (Morales-Muñoz et al., 2016). Although we have obtained a possible cause, not associated with equinus of the foot, it would still be beneficial to manage any potential risk factors so that recovery from this condition is not hindered.

This patient was very active and reluctant to rest from his running activity as advised so in order to ensure that he does so, we had a discussion on methods to fulfil his fitness needs without the need of overloading his feet. We suggested a plan of swimming and cycling, which the patient seemed to respond to in a much more positive manner.

References – 

Besse, J.-L. (2016). Review article Metatarsalgia. 103, 29–39. https://doi.org/10.1016/j.otsr.2016.06.020

Blyth, M., Anthony, I., Francq, B., Brooksbank, K., Downie, P., Powell, A., … Norrie, J. (2015). Diagnostic accuracy of the thessaly test, standardised clinical history and other clinical examination tests (Apley’s, mcmurray’s and joint line tenderness) for meniscal tears in comparison with magnetic resonance imaging diagnosis. Health Technology Assessment. https://doi.org/10.3310/hta19620

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

Galli, M., Ciriello, V., Menghi, A., Aulisa, A. G., Rabini, A., & Marzetti, E. (2013). Joint line tenderness and Mcmurray tests for the detection of meniscal lesions: What is their real diagnostic value? Archives of Physical Medicine and Rehabilitation. https://doi.org/10.1016/j.apmr.2012.11.008

Hinman, R. S., Hunt, M. A., Creaby, M. W., Wrigley, T. V., McManus, F. J., & Bennell, K. L. (2010). Hip muscle weakness in individuals with medial knee osteoarthritis. Arthritis Care and Research. https://doi.org/10.1002/acr.20199

Howell, R., Kumar, N. S., Patel, N., & Tom, J. (2014). Degenerative meniscus: Pathogenesis, diagnosis, and treatment options. World Journal of Orthopaedics, 5(5), 597–602. https://doi.org/10.5312/wjo.v5.i5.597

Jevsevar, D. S. (2013). Treatment of osteoarthritis of the knee: Evidence-based guideline, 2nd edition. Journal of the American Academy of Orthopaedic Surgeons. https://doi.org/10.5435/JAAOS-21-09-571

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

Morales-Muñoz, P., De Los Santos Real, R., Barrio Sanz, P., Pérez, J. L., Varas Navas, J., & Escalera Alonso, J. (2016). Proximal Gastrocnemius Release in the Treatment of Mechanical Metatarsalgia. Foot and Ankle International. https://doi.org/10.1177/1071100716640612

Picha, K. J., & Howell, D. M. (2018). A model to increase rehabilitation adherence to home exercise programmes in patients with varying levels of self-efficacy. Musculoskeletal Care. https://doi.org/10.1002/msc.1194

Rutjes, A. W., Nüesch, E., Sterchi, R., & Jüni, P. (2010). Therapeutic ultrasound for osteoarthritis of the knee or hip. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.cd003132.pub2

Zhang, C., Xie, Y., Luo, X., Ji, Q., Lu, C., He, C., & Wang, P. (2016). Effects of therapeutic ultrasound on pain, physical functions and safety outcomes in patients with knee osteoarthritis: A systematic review and meta-analysis. Clinical Rehabilitation. https://doi.org/10.1177/0269215515609415