Marjon Clinic – 17th November 2020 for 5 hours

Management of the clients that came into clinic this week was very much exercise based. I incorporated a variety of activities including eccentric strengthening, pelvic floor activation and High Intensity Interval Training (HITT).

Reflective Summary

My first client had been experiencing a dull ache at the bottom of the calf. They had previously had plantar fascitis in the same leg, so were worried it was related and may stop them from running. A week had passed since her online consultation, so when she came into clinic with me she no longer had pain which was really positive. The main focus of the session was beginning to increase both isometric and eccentric strength of the calves. As part of this I utilised the Alfredson protocol. The protocol involves a programme of eccentric heel drop exercises that has been well documented for achilles tendon injury rehabilitation (Stevens & Tan, 2014). Despite this, it can be an option for gastrocnemius injuries as the calf muscles and achilles tendon work together as part of the same musculotendinous unit (Coffey & Khan, 2020). Flywheel training is a relatively new training method that targets the human body with continuous resistance and eccentric overload (Wonders, 2019). I came across this method when I was researching eccentric training for the calf muscles and discovered it could be utilised within musculoskeletal rehabilitation. I could use flywheel training with my client; flywheel squats have been shown to lead to structural adaptations in the gastrocnemius muscles (Sanz-López, Berzosa Sánchez, Hita-Contreras, Cruz-Diaz, D & Martínez-Amat, 2016). Moreover, calf raises can be done as a flywheel exercise and can begin in the proliferation stage of tissue healing (Wonders, 2019). Both early rehabilitation and flywheel training combined with strength and functional exercises could result in enhanced outcomes in patients after a calf strain.

The windlass mechanism is another method that can be used specifically for plantar fascitis. The mechanism describes the manner by which the plantar fascia supports the foot during weight bearing activities and provides information regarding stresses placed on the plantar fascia (Bolga & Malone, 2004). Strengthening should facilitate the windlass mechanism; this can be done by placing a towel under the feet when performing calf raises and heel drops. This will put increased pressure through the calves and plantar fascia.

For my final client, they wanted to be guided through some pelvic floor exercises. Pelvic floor disorders are common among women and tend to be caused by relaxed pelvic floor muscles (Faubion, Shuster & Bharucha, 2012). Symptoms associated with pelvic floor dysfunction include urinary incontinence, sexual dysfunction and pain. In order to activate pelvic floor muscles, we can inform clients about the anatomy of the pelvic floor and how to contract the pelvic floor muscles correctly before exercise (Ko et al., 2011). Ko et al. (2011) investigated the effectiveness of antenatal pelvic floor muscle exercise in the treatment of pregnancy and postpartum period. They found that the exercises were effective in the treatment of unitary incontinence. Exercises for pelvic floor dysfunction included heel bridges, bird dog, dead bug and assisted heel drops. These can be used within prevention as well. After the session, I had a really interesting discussion with the client. They were very passionate about pelvic floor dysfunction and felt that it should be discussed more and should not be seen as a negative thing. This is important with menopause as well.

Areas for Improvement Action Plan
When doing HIIT sessions I can  use the Rate Perceived Excursion (RPE) scale in order to understand how hard the client is working Print the RPE scale off and find out what number not only relates to HITT but other forms of exercise as well
Even if a client if further on a rehab, I still need to use objective markers -> a pain dairy is a good way for the client to identify if they get pain before, during or after activity. They can also note the terrain, speed, duration and frequency Research other effective methods that can be used as objective markers
Ensure I write down the frequency per week for the exercises Write a reminder on the cliniko notes when researching exercises before the appointments

Closing the Loop

Another method that I can use for objective markers includes questionnaires which could either be more generic and relate to functional lifestyle activities or be specific to the pathology such as The Copenhagen Hip and Groin Outcome Score (HAGOS) for hip and groin pathologies. Not only do I remember to include sets and reps for each exercise, I advise the clients on how may days a week they should be completing the rehab programme.

References

Bolgla, L. A., & Malone, T. R. (2004). Plantar fasciitis and the windlass mechanism: a biomechanical link to clinical practice. Journal of athletic training, 39(1), 77.

Coffey, R., & Khan, Y. S. (2020). Gastrocnemius Rupture. StatPearls [Internet].

Faubion, S. S., Shuster, L. T., & Bharucha, A. E. (2012). Recognition and management of nonrelaxing pelvic floor dysfunction.Mayo Clinic Proceedings. 87(2),187-193.

Ko, P. C., Liang, C. C., Chang, S. D., Lee, J. T., Chao, A. S., & Cheng, P. J. (2011). A randomized controlled trial of antenatal pelvic floor exercises to prevent and treat urinary incontinence. International urogynecology journal, 22(1), 17-22.

Sanz-López, F., Berzosa Sánchez, C., Hita-Contreras, F., Cruz-Diaz, D., & Martínez-Amat, A. (2016). Ultrasound changes in achilles tendon and gastrocnemius medialis muscle on squat eccentric overload and running performance. Journal of Strength and Conditioning Research, 30(7), 2010-2018.

Stevens, M., & Tan, C. W. (2014). Effectiveness of the Alfredson protocol compared with a lower repetition-volume protocol for midportion Achilles tendinopathy: a randomized controlled trial. journal of orthopaedic & sports physical therapy, 44(2), 59-67.

Wonders, J. (2019). Flywheel Training in Musculoskeletal Rehabilitation: A Clinical Commentary. International Journal of Sports Physical Therapy, 14(6), 994.

 

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