Marjon Clinic – 19th January 2020 for 4 hours

This week, I had two online consultations; one client presented symptoms of a grade one calf strain whereas the clinical impression for the other client was dysfunction of the costovertebral / facet joint at the level of T8/T9.

Reflective Summary

My first appointment was reasonably straight forward as the client was nearing the end stage of a grade 1 calf strain. They were only ‘aware’ of pain during a single leg calf raise so this can be used as a clinical marker to measure improvements. Because of this, the rehabilitation programme was based around strengthening the calf muscles and included exercises such as resisted plantar flexion, single leg calf raises and eccentric calf raises.

The second client was an interesting case, as they experienced a sharp pain (8/10 VAS) at approximately T8/T9 due to intense impact. Due to the location of pain, the clinical impression was stiffness of the costovertebral joint with a different diagnosis of facet joint dysfunction. Although, they did appear to have good range of movement so exercises were focussed on strengthening rather than increasing movement. The exercises which I prescribed included serratus presses, kettlebell drag through and shoulder shrugs so emphasised working in different thoracic plane of movements.

If I was able to see the client face to face, I would want to do mobilisations on the costovertebral and facet joint at the level of discomfort. PA mobilisations are rhythmic, oscillatory movements applied to the spinous or transverse process of a vertebra, in order to decrease pain and stiffness therefore improve ROM (Snodgrass & Odelli, 2012). Therapists select one of four grades of mobilisations, that are described by the relationship between resistance or spinal stiffness palpated and ROM perceived by the therapist (Snodgrass, Rivett, Robertson, & Stojanovski, 2010); Grade 1 is a small amplitude movement near beginning of range and not in resistance, Grade 2 is a  large amplitude movement well into range that is free of resistance and muscle spasm, Grade 3 is a  large amplitude movement into resistance and muscle spasm and Grade 4 is a small amplitude movement stretching into resistance and spasm at the end of the available range (Mahakul, Singh, Sahoo, & Samant, 2017). I would begin with a grade 1/2 to try and reduce pain. As I am unable to do this, I have included self-mobilisation in the exercise prescription, so the client can replicate this technique as much as possible.

They also explained that there is the possibility that they have ankylosing spondylitis (AS); AS is an autoimmune disease that affects the joints of the spine where the main clinical characteristics include back pain and progressive spinal rigidity (Zhu et al., 2019). Diagnostic imaging can be used such as Magnetic Resonance Imaging (MRI) in order to detect AS so this would be necessary to confirm it. An MRI can aid in early recognition of inflammation of the spine, since it can detect active inflammatory changes (Raychaudhuri & Deodhar, 2014).

What Went Well

I did a thorough subjective assessment with both clients, so I was able to get as much information as possible, especially as current appointments are virtual.

Areas for Improvement Action Plan
Communicating how to do the particular joint movements on an online consultation Practice communicating the range of motions of at each joint
Understand the common signs and symptoms of a variety of pathologies Research these pathologies and create mind maps to show the information
Continue to develop exercise prescriptions for different pathologies Begin to create videos to upload onto my professional Instagram

Closing the Loop

Since completing these hours, I have had a lot more experience with virtual appointments, therefore my communication has improved, especially when asking the client to perform movements. I have began to create mind maps of different pathologies and have produced a word document containing a variety of exercises, each with there own description and what they can be used for.


Raychaudhuri, S. P., & Deodhar, A. (2014). The classification and diagnostic criteria of ankylosing spondylitis. Journal of autoimmunity, 48, 128-133.

Snodgrass, S. J., & Odelli, R. A. (2012). Objective concurrent feedback on force parameters improves performance of lumbar mobilisation, but skill retention declines rapidly. Physiotherapy, 98(1), 47–56.

Snodgrass, S. J., Rivett, D. A., Robertson, V. J., & Stojanovski, E. (2010). Cervical spine mobilisation forces applied by physiotherapy students. Physiotherapy, 96(2), 120–129.

Zhu, W., He, X., Cheng, K., Zhang, L., Chen, D., Wang, X., … & Weng, X. (2019). Ankylosing spondylitis: etiology, pathogenesis, and treatments. Bone research, 7(1), 1-16.

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