Client 1:

The first client that came into the clinic had a stiff thoracic spine, that was most probably causing tension in the shoulders. They also had symptoms of lateral epicondylitis including occasional shooting/burning pain and tight wrist extensors. From the subjective assessment we understood that she was a shop assistant, stacking shelves, which makes sense why she is getting problems in both the shoulders and right elbow (dominant arm). The treatment began with STM of the rhomboids and upper traps, in order to release some of the tightness. Central mobilisations of the thoracic spine were used at a grade 3, which aims at decreasing stiffness, therefore improves range of movement (ROM). It was also important to focus on the lateral epicondylitis, as this is more of an issue. STM was used through the extensors (on the lateral side), STR over tenderness and finally physiological mobilisations of the wrist, for both flexion and extension. An exercise prescription was given to the client in order to begin to strengthen the shoulder and forearm. Previously, the activities prescribed were more concentric, but as progression had been made by the client, the exercises given could be more eccentric. Exercises included external rotation (ER) of the shoulder using dumbbells, which can be progressed to ER in the howl position and finally with the shoulder at 90 degrees, bringing the arm to 90 degrees of horizontal abduction (with a weight), without dropping the arm.

During the 5 hours, I was also able to practice a variety of manual therapies on a qualified sports therapist. Before I did thoracic mobilisations, I needed to check ROM in sitting. The movements tested included flexion, extension, side flexion and rotation. While the client is performing these movements, observe from the side and back, in order to see how the spine is moving and if there are any restrictions during certain movements. Once objective measures were complete, I started with mobilisations. It is important to feel for stiffness first, to understand whether it is central or unilateral, so I knew whether to treat over the spinous processes (SP) or transverse processes (TP). Once I had identified this, I mobilised centrally at a grade 3 for 30 seconds per joint. At the end of treatment, I checked ROM again, to see if the method had been effective and it had, as there was an improvement in range. As I had never massaged the arm before, I got the chance try it, utilising the same methods of massage that I would normally use. I also used STR which is where the muscle (in this case the wrist extensors) is shortened, pressure is then applied to a trigger point and the muscle gets slowly lengthened so it is stretched. The final thing I practiced was mobilisations of the wrist using physiological movements, both flexion and extension.

Client 2:

The final client was a lady who had recently began running doing 1-2 miles at a time. They explained that they had tender claves and sore shins, therefore it could be possible shin splints or even a stress fracture. From the clinical assessment we found out that they have very high arches. Treatment wise, STM was used on both calves in order to release some tension and accessory movements (mobilisations) were applied to the ankle joint in order to increase ROM. Once the treatment was finished, we got the client to put on their running shoes so we could observe their gait during walking (as they still had pain). We noticed that there left foot (affected side) gave way inwards which could explain the pain. The trainers looked like they were not supporting the foot, therefore did not stop it from moving in. The client was given exercises to continue to do, including calf raises and proprioceptive activities like balancing on one leg and closing the eyes to make it harder. The therapist advised the client that they may need more supportive trainers but she wanted to observe her run next time to see if the foot went inwards when running.

Areas for further improvement

My first area for further improvement would be to practice and perfect STR on different areas of the body. In order for it to successful, apply the same generic technique each time by shortening the muscle you want to affect, apply a lock towards the origin and then lengthen and stretch the muscle. To perform this effectively it would also be good to revise the anatomy so that I know the exact location of the muscle that I want to treat. My final area for improvement would be to ensure that when I am explaining the methods of treatment to a client, I am using simple vocabulary, so that they can understand what I am describing.

Things to Remember 

1. When mobilising the spine, miss a vertebra out, as the mobilisations can affect the joint underneath
2. Explain what treatment methods you will use on the client
3. Always ask the client about the frequency and intensity of the pain
4. Rule of threes: T1-T3 = SP is in line with TP, T4-T6 = SP is ½ a level down from TP, T7-T9 = SP is in line with TP, T10-T12 = SP is down from TP
5. For the thoracic spine assess ROM in sitting so that the lumbar spine cannot affect the range
6. Avoid using lumbar mobilisations if the client has increased lordosis, it will only make the lordosis worse