Running total of hours 156.5
Patient 1 – Previous history of strain in erector spinae
All assessment of this patient indicated the muscular involvement was most likely. The pain was localised and muscle testing provoked pain with resisted movements and any passive motions unprovocative. No indication of joint pathology and due to the chronic nature of the pain and subjective onset last year, I was confident that this treatment would be strengthening based, with passive modalities such as STM and stretching feasible options.
One of the most important elements to treatment and rehabilitation is the goal of the session and regardless of what stage of injury the patient is in, what they hope the outcome to be, determines the course of treatment and our approach as therapists.
At present, the pain in this patient’s back was low and of minimal irritability, but his anxieties led him to believe that he may not fully enjoy his sport again due to the constant feeling of discomfort. This apprehension and anxiety will only serve to hinder progress and potential exercise adherence and so with some motivation and positive communication, my aim was to encourage this patient to commit to a more regular exercise schedule.
The patient showed little enthusiasm and belief in the effectiveness of strengthening exercises in the treatment of his pain at the beginning of the session, however after taking the time to through each exercise and explaining the rationale behind them, he left the clinic feeling more empowered; the patient commented on his renewed motivation since returning to the clinic.
The exercises that I prescribed included glute bridges with additional resistance bands around the thighs to activate the lateral abductor muscles (Gasibat et al., 2017), as this patient also presented with weakness here as well as a dull pain in his lateral thigh.
I did not feel comfortable knowing how to test this patient’s source of pain, which is undoubtedly the result of poor anatomy knowledge and have since worked to develop this. I have found the following video incredibly useful in knowing how to individually test each quadricep muscle and other muscles on the lower leg.
This video by the PhysioTutors also helped me to consider a more accurate approach to muscle testing. I have previously thought that muscle testing and grading was a difficult skill acquired from experience, as I have never felt myself an accurate judge of muscular strength, however this video differentiated between each grade with specific and easy to understand guidelines.
Other exercises included the side plank with hip abduction (Gasibat et al., 2017)and the deadlift squat (Camara et al., 2016).
I was unsure as to whether this patient needed to perform this squat with bent or straight needs and I asked for guidance, however I was able to work out the mechanism in this movement and therefore the rationale between each; deadlifting with bent knees excludes the hamstring in this motion, so in order to isolate the erector spinae alone, the patient should keep their knees bent.
It was also suggested that the patient consider the possibility of using a hexagonal barbell instead of a straight one in order to maintain a more even load throughout, as recommended by Camara et al. (2016) in a study that found differences in outcomes between both the hexagonal and straight barbells when performing a squat; the hexagonal barbell was found to better distribute load throughout the joints compared with the straight bar bell. Although deadlifting with a straight bar is generally good way to increase lumbar strength, in the case of lower back pain, prescribing an exercise which predominantly activates lower back and hamstrings may only aggravate symptoms.
Patient 2 – Achillies Tendonitis Exercises
I had plenty of time before this patient arrived and fortunately the clinic was quiet, so myself and two other students engaged in a conversation on tendinopathies to help us to understand the pathology behind the condition so that we can fully appreciate our treatment subscription.
Fortunately, we had also attended a lecture in recent weeks which focused heavily on the differences between tendonitis, tendinopathy and tendinosis, so I was able to recall some knowledge on this to help enhance my ability to differentiate between the pathologies during the diagnostic process and prescribe the correct rehabilitation. This was especially important in this patient as this patient had left a note on his booking which informed me of his main goals for the session which was to receive an appropriate exercise plan to facilitate his return back to running.
We referred back to the lecture notes from Gary Schum to look to derive an appropriate exercise prescription. Early research by Fahlström et al. (2003) found that eccentric exercises were useful in reducing pain and improving symptoms in chronic mid portion tendinopathy, as was the case with this patient.
In the presence of symptomatic pain, it is recommended that isometric contractions should be used, as these have been reported as inhibiting pain responses (Naugle et al., 2012; Rio et al., 2015), specifically low duration with low to moderate intensity (20-50% contractions).
The benefits of isometric contractions are that they can be performed without the reduction of strength and as found by (Rio et al., 2015) in a study on patella tendinopathy, isometric contractions were effective in reducing pain for up to 45minutes after the exercises.
It is important to differentiate between insertional and mid portion tendinopathies as this would determine the treatment prescription in so much as stretching and exercises must not effect areas that may compress the insertional aspects of the tendon. It may be useful to perform other means of lengthening and stretching of associated musculature, such as the triceps surae group by way of foam rolling or STM.
In this case, the pain was very much localised to the mid portion aspect of his achillies tendon and as such exercises that may increase compression of this area were not excluded and stretching could be performed by this patient, even in the reactive stage.
Recently in my reflections, I delved into the different stages of tendinopathy, however I was not fortunate enough to come across an article by Cook and Purdam (2009) of which I have found extremely useful.
Often in my practice, I am aware of the available research and therefore rationale behind the treatment and rehabilitation, however I am not always able to explain the pathology behind the injury and therefore without this knowledge, it is difficult to rationalise the treatment. Instead, I rely too heavily on research findings are recommendations, without a depth of knowledge as to why this evidence was found.
In this particular case of achillies tendinopathy, I am confident in considering eccentric exercises to aid in the strengthening, but I am unsure as to why.
It is also important to know at which point to start the patients on eccentric strengthening but with more knowledge as to the rationale behind them, I may be able to understand this better.
As reported by Cook and Purdam (2009), load is the main variant in tendon health and in most cases, according to Quinlan et al. (2019), appropriate loading of the achillies tendon results in physiological adaptations of the tissue. The theory behind the continuum, as reported by Cook and Purdam (2009) is that varying loads can determine the progression or regression of a tendon pathology.
When the tendon is overloaded acutely it is most likely to be reactive tendinopathy and although some structural changes occur in the matrix, such as collagen deformation, it is unlikely to be observed or relevant at this stage. However, in the case of tendon disrepair, matrix breakdown becomes greater and neovascularisation does start to occur and can be seen on diagnostic imaging (Cook & Purdam, 2009).
NB: the group discussion during clinic today was very useful, as I was not sure exactly what neovascularisation was and as it is relevant to achillies tendinopathy, I am pleased we were able to clarify what this was.
This stage is more the result of chronic overload and would likely be the stage in which this patient is in due to his subjective history. The fact that this patient had been overtraining over the course of many years in spite of severe pain and inflammation would suggest that chronic overload should be considered a probably and likely cause.
I was initially confused by the fact that this patient had rested for the previous year and wondered why this had not had an positive effect on his tendon. It was explained that the chronic overuse was in fact accumulative and that although he had stopped, the damage had already occurred and physiological adaptations would likely have taken effect (such as matrix breakdown and neovascularisation).
it was reassuring to read however that these changes could be reversed with the correct loading program (Cook & Purdam, 2009).
A recent review by Quinlan et al. (2019) was unable to differentiate between concentric or eccentric exercises and could not conclude whether one was more effective than the other however, it was suggested that the use of eccentric exercises for older patients could be useful as it required less perceived effort.
It is reported that loading can have an effect on the tendon up to three days after intense loading and therefore it may be that in order to prevent excessive loading, the patient could ensure a period of at least three days of rest before further loading the tendon as opposed to training on a daily basis (Cook & Purdam, 2009).
If loading is the issue, which it most likely is in reactive tendinopathy it may be recommended that low impact, low elastic training be performed such as cycling or swimming as opposed to activities that require running or jumping mechanisms. Educating the patient on stride length may also be appropriate.
When this patient has visited other professionals, he was recommended to load the tendon, with exercises prescribed which were all predominantly eccentric. I would previously have done the same, as it has been widely reported that this is the most effective treatment. However, now that I am more understanding of the continuum model, I am more aware of the differing nature of the pathology and the need to adapt the rehabilitation accordingly.
Patient 3 – Lower back pain and core stability
This patient presented with generalised and non-specific lower back pain and has requested a STM to treat the symptoms of this. The patient had reportedly tried strengthening programs and other means such as stretching and mobility exercises to help manage his symptoms but to no avail. In all previous appointments where I have managed to find recommended exercises of good feasibility, I have yet to fully appreciate their effectiveness because I am early on in their rehabilitation programs; I have not seen the patient enough times to fully notice any long term improvements.
But, if this patient is now failing to notice and improvements in symptoms in spite of a comprehensive exercise program, as well as reviewing this program and looking for potential reasons for it’s ineffectiveness, for example making an adjustments to his technique, I could look to find an alternative route of treatment. For example core stability.
According to Gordon & Bloxham (2016), although improving lumbar spine and hamstring flexibility reduced chronic lower back pain by 18.5 to 58%, core stability exercises were found to be more effective than stretching. It was also found that core strengthening reduced chronic lower back pain by up to 76.8% whereas muscular strength exercises, although also effective, reduce chronic lower back pain by just 61.1% (Gordon & Bloxham, 2016). A study by Chang et al. (2015) reviewed previous research findings on the effectiveness of core exercises and their specific nature, reporting the following as effective with the general pattern of up to two sessions a week for between six to ten weeks.
Trunk exercises while quadruped or otherwise (such as sitting or kneeling but not standing), segmented stabilisation exercises and more dynamic movements such as the cat camel, concentrating on breathing in particular, were all incorporated in these programs.
It was interesting to read the consideration of breathing techniques as I did not take this into account when prescribing this to my patient, yet it is a very important aspect of these exercises.
This may be common sense, but it was also reported that the length of the core stability program was also a factor in its effectiveness, with a three week program proving less effective than an eight week one (Gordon & Bloxham, 2016) and as such I will look to educate future patients in the importance of maintaining their programs beyond their perceived need and beyond as a way of ensuring long term benefits and reducing regression. This patient was now fully aware of the advantages of maintaining an exercise program for longer periods of time and to persevere with this until symptoms may start to reduce (and beyond). Also, I felt that we could add another dimension to the program by way of core stability and as such I incorporated some exercises to enhance this.
Exercises such as the bird dog, bridges and side planks were all prescribed with high volume and repetitions with the aim to improve muscular endurance rather than strength.
Patient 4: STM of lower back, glutes and piriformis release with additional PA of L4/5
Extra Reading and discussion during time between patients:
Core stability in general – is it effective?
In any scenario within my practice, I will look to include core stability exercises in rehabilitation. My rationale behind this is due to the enhanced risks that poor core stability brings to an athletes. De Blaiser et al. (2018) highlights the risk factors in athletic injury of the lower limb, finding that neuromuscular control, core strength, endurance and proprioception all increase the likelihood of injury and that core exercises can be used to either prevent injury or help to facilitate back to play in rehabilitation programs.
In an article by Huxel Bliven and Anderson (2013), a table of core stability exercises was created which includes the specific muscle recruitment and therefore specific areas of strengthening.
I will print this off as a reference guide for me to use in clinic and the findings in this study can be referred to as a means to rationalise the use of these exercises, should this be questioned.
I could not upload the table to this blog as the quality was poor, so please see the following link to the article with reference to p. 520.
Camara, K. D., Coburn, J. W., Dunnick, D. D., Brown, L. E., Galpin, A. J., & Costa, P. B. (2016). An examination of muscle activation and power characteristics while performing the deadlift exercise with straight and hexagonal barbells. Journal of Strength and Conditioning Research. https://doi.org/10.1519/JSC.0000000000001352
Chang, W. D., Lin, H. Y., & Lai, P. T. (2015). Core strength training for patients with chronic low back pain. Journal of Physical Therapy Science, 27(3), 619–622. https://doi.org/10.1589/jpts.27.619
Cook, J. L., & Purdam, C. R. (2009). Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British Journal of Sports Medicine. https://doi.org/10.1136/bjsm.2008.051193
De Blaiser, C., Roosen, P., Willems, T., Danneels, L., Bossche, L. Vanden, & De Ridder, R. (2018). Is core stability a risk factor for lower extremity injuries in an athletic population? A systematic review. Physical Therapy in Sport. https://doi.org/10.1016/j.ptsp.2017.08.076
Fahlström, M., Jonsson, P., Lorentzon, R., & Alfredson, H. (2003). Chronic Achilles tendon pain treated with eccentric calf-muscle training. Knee Surgery, Sports Traumatology, Arthroscopy. https://doi.org/10.1007/s00167-003-0418-z
Gasibat, Q., & Simbak, N. Bin. (2017). Modified Rehabilitation Exercises to Strengthen the Gluteal Muscles with a Significant Improvement in the Lower Back Pain. 2(1), 20–24. https://doi.org/10.17758/eirai.f0217730
Gordon, R., & Bloxham, S. (2016). A Systematic Review of the Effects of Exercise and Physical Activity on Non-Specific Chronic Low Back Pain. Healthcare, 4(2), 22. https://doi.org/10.3390/healthcare4020022
Huxel Bliven, K. C., & Anderson, B. E. (2013). Core Stability Training for Injury Prevention. Sports Health. https://doi.org/10.1177/1941738113481200
Naugle, K. M., Fillingim, R. B., & Riley, J. L. (2012). A meta-analytic review of the hypoalgesic effects of exercise. Journal of Pain. https://doi.org/10.1016/j.jpain.2012.09.006
Quinlan, J. I., Narici, M. V, Reeves, N. D., & Franchi, M. V. (2019). Tendon Adaptations to Eccentric Exercise and the Implications for Older Adults. Journal of Functional Morphology and Kinesiology. https://doi.org/10.3390/jfmk4030060
Rio, E., Kidgell, D., Purdam, C., Gaida, J., Moseley, G. L., Pearce, A. J., & Cook, J. (2015). Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. British Journal of Sports Medicine, 49(19), 1277–1283. https://doi.org/10.1136/bjsports-2014-094386