Marjon Clinic – 16th March 2021 for 5 hours

This was my first time back at clinic since December, so I was excited to get back to treating and rehabilitating a range of clients. My first client came in for a face to face appointment with a clinical impression of costovertebral dysfunction. I also had a virtual consultation with another client who was approximately one week post spinal surgery.

Reflective Summary

The first client reported a sharp twinge in the left shoulder blade which radiated down the medial border of the scapula. They had previously reported that they had pain while taking deep breaths, which promoted the clinical impression of costovertebral dysfunction; the costovertebral joint complex is mechanically involved in both respiratory function, therefore explains why the client would get pain during breathing, as well as thoracic spine stability (Beyer et al., 2016). These joints facilitate the attachment of the ribcage to the throat spine which increases the stability of this section of the spine (Petersen, 2017).

During the objective assessment I palpated the the costovertebral joints on the left and right side. The stiffness was present on the left side, therefore I conducted posterior to anterior (PA) joint mobilisations from T4-T7. PA mobilisations are rhythmic, oscillatory movements that are applied to specific joints of the spine, in order to decrease pain and stiffness therefore improve range of movement (ROM) (Snodgrass & Odelli, 2012). I utilised grades 3 and 4 as they provide the most effective outcomes by increasing the ROM of the costoverterbal joints. A grade 3 is considered a large amplitude movement into resistance and muscle spasm whereas a grade 4 is a small amplitude movement stretching into resistance and spasm at the end of the available range (Mahakul, Singh, Sahoo, & Samant, 2017). Clincial measures were utilised to understand if the treatment method was effective; improvements in ROM were seen for cervical and thoracic side flexion as well as lumbar rotation. In order to maintain this range thoracic mobility exercises were prescribed, this included quadruped T spine rotation, thread the needle, childs pose rotation and cat-cow with an emphasis through the thoracic spine.

What Went Well

I was confident in my treatment selection for the client with costovertebral dysfunction and was happy to see that improvements were made in their ROM when I re-tested it after mobilisations were conducted. I continue to ensure I complete my notes to an excellent standard so that other therapists are able to understand my work.

Areas for Improvement Action Plan
Encourage clients to not become reliant on massage Explain to the clients how massage is considered for short term pain relief whereas a more exercise-based approach could help with symptoms long term
Understand the different types of spinal surgery that may occur Research different pathologies of the spine that may require surgery and what the rehabilitation could be for each stage, while considering any contraindications

Closing the Loop

Since writing this reflection, I have researched the contraindications for each stage of rehabilitation, specifically for a lumbar discectomy. Movements that should be avoided up to six weeks after the operation can include twisting, bending as well as pushing, pulling and lifting anything more than 5 lbs.


Beyer, B., Jan, S. V. S., Chèze, L., Sholukha, V., & Feipel, V. (2016). Relationship between costovertebral joint kinematics and lung volume in supine humans. Respiratory physiology & neurobiology, 232, 57-65.

Mahakul, B., Singh, H., Sahoo, J., & Samant, S. (2017). Effectiveness of Maitland mobilisation technique on pain and hand functions in the postoperative management of Colles fracture. International Journal of Orthopaedics Sciences, 3(3), 397–399.

Petersen, G. E. D. S. (2017). The effect of thoracic spine manipulation compared to thoracic spine and costovertebral joint manipulation on mechanical mid-back pain at the Durban University of Technology Chiroptractic Day Clinic (Doctoral dissertation).

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.

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