16 April. Duration 6hrs (4 clients)
My first client; a 60-year-old male, had attended his GP with a long standing (5-years) prolapsed disc (L5/S1), which impacted his right side more and advised he had previously had corticosteroid injections (Wilby et al., 2021), which helped initially, but then pain returned and he was now on long-term anti-inflammatory medications, had his own TENS unit (Dias et al., 2021) and had tried acupuncture, physical therapy at Derriford Hospital and private chiropractors, all with varying degrees of success, but wished to try Marjon clinic as a friend provided good reports.
I discussed his current pain, and mobility, and he advised he was currently feeling fine, and was able to provide good examples of classic pain associated with an L5/S1 disc herniation, with pain running down the back of his leg, but rarely going into his foot. He advised, he was relatively mobile now, but often had some tingling and numbness at the L5/S1 site when it was sore, stating it could be triggered by the slightest of movements. The client advised it had never impacted his bladder/bowel movements.
I was relatively cautious with this patient, as I did not wish to exacerbate his condition (de Sire et al., 2021) however, as he was stable now, I got patient to do some passive ROM, and from observation, decided to do some palpation on L5/S1 site, which was tender over L5 region, I did some active ROM, which indicated restricted and active flexion, extension and bilateral lateral flexion (more on his right side), prior to conducting a few tests advising him if he felt any pain to inform me and stop immediately (straight leg/slump test/walking on heels/toes test). The heel test particularly highlighted his injury, as he was unable to stay on his right heel as it caused discomfort, but generally he displayed all the signs of a positive herniated disc. At this stage, the client was feeling a bit tense, hence I decided to stop to allow him to rest for 5-minutes by lying down, which he appreciated. Post this I advised him I was going to do some gentle mobilizations and extension exercises, but I first got him to walk and sit as he would normally, and noted he had a slight hunch when walking and when sitting on a straight-backed chair, he tended to slump forward, putting pressure on his spine. I wished to start very slowly, hence instructed him to always be careful & use support when getting up or down, and never bend over at the hip minus bending his knees first. At times during the stretching session, the client was really working hard, and it was a pleasure to work with him, as it was obvious, he really wanted to get better. We conducted some sitting neck stretches; seated hamstring stretches; towel or band hamstring stretch laying on his back; back flexion’ knee to chest stretch; piriformis muscle stretch. I advised the client to continue doing gentle activities and exercises whilst feeling good, to strengthen his muscles supporting the spine, which will reduce pressure on his spinal column, whilst also promoting flexibility in the spine, which may help to reduce the risk of a herniated disk recurring. I informed him not to do any exercises or stretches, which placed direct pressure on his spinal column, such as lifting weights and always to do things slowly and in a controlled fashion. Leisurely swimming, walking, or cycling were generally good sports to partake in.
The client thanked me for the session, advising it was highly informative and beneficial, and he would continue to do the exercises. If I could have done anything differently, I would have included some STR.
I was assisting a supervisor with the next patient today, a 20-year-old rugby back player recovering from a partial tear of his anterior cruciate ligament (ACL), and in phase 4 of rehabilitation. The client had conducted three sessions to date. We had a functional and plyometric progressive programme prepared including running technique drills, agility, and speed exercises, with some dynamic explosive movements and cone pick-ups, crossover and tyre stepping exercises to improve proprioception, which is needed in rugby backs for catching the ball and quick turns. Resistance band jump; hopping exercises; step back; box jumps, and some rugby ball passing and change of directions at 20% to 50% pace. Conducting this training was beneficial for me, as I had not done this late stage of recovery training with a rugby player previously, and noted how progressive loading (Gabbett, 2020; Windt et al., 2017) and constant checking with the client post exercises worked, especially the requirement for constant communications. I will take this away with me for future use. I also noted how clients must be tightly controlled during this phase of recovery, as their exuberance to progress and prove their fitness is very evident, which could so easily end badly if allowed to keep pushing.
My next client was a 36-year-old female office worker. The client had experienced a calf strain three days previously when she slipped coming out of the water at Plymouth sound, after an open water swimming session, explaining she twisted awkwardly to try and regain her balance, which was when she felt a twinge in her right calf, which was now aching slightly. I conducted an assessment noting there was no bruising, swelling or redness at the site of the injury, and through passive/active ROM, her movement was not impacted. As the client was passed the 72-hour mark, I deemed it safe to conduct massage if there was no contraindications i.e. rheumatoid arthritis, gout, bleeding disorders etc, which she did not have and through observation for any other signs, especially deep vein thrombosis (DVT) using the Wells Clinical Prediction Rule (pdf) / Wells Clinical Prediction Rule for Pulmonary Embolism (online), which was negative. I observed both legs to identify any asymmetry or unilateral swelling, skin changes, wounds, oedema, erythema, varicosities and for excessive heat in the wound area. I was satisfied, it was safe to continue, and believed this was a grade 1 strain, which likely occurred through a combination of her muscles being cold in the water and action of a sudden jerky movement. With feet hanging over table conducted a light effleurage followed by petrissage finishing with petrissage light effleurage techniques. As this client was clearly physically active, I demonstrated some stretching exercises to conduct at home, to stretch her gastrocnemius and soleus muscles, and advised her to do these 3-5 times per day until the strain had dissipated. If I could have done anything differently, I would have asked more questions reference previous injuries she may have had of the lower limbs, but the client was happy with the treatment and information provided, advising she would return if required. I informed the client, to rest from physical activity; including sea swimming, until her injury healed, but if it did not feel better within 4-5 days, she should visit her GP, who may conduct other testing or send her for an MRI scan. I was pleased with this session, as I believe I covered a lot of ground in a relatively short period of time and know my experience and consequently confidence level is increasing.
My final client today, was a returnee dancer, I had last seen on 24th March ’21. She was suffering from GP diagnosed piriformis syndrome. I conducted an assessment and observation inclusive of passive/active ROM and was happy to see she currently had no pain in her hip or clicking. I performed STR in her piriformis muscle area followed by a warmup and then stretching and strengthening exercises, using increased resistance band strengths, side lying clams and hip extension exercises with light loading. I informed the dancer, she could return to ‘active’ dancing, but must continue to really focus on flexibility and strengthening exercises as part of her daily routine. I finished the session off by informing her to really warp up and down after each dancing session, and to continue to build her strength using all the stretches and strengthening exercises provided as part of her daily dance routine. I was extremely happy to see this dancer had adhered to her programme and made a good recovery.
References
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Invernizzi, M. (2021). Oxygen–Ozone Therapy in the Rehabilitation Field: State of the Art on Mechanisms of Action, Safety and Effectiveness in Patients with Musculoskeletal Disorders. Biomolecules, 11(3), 356.
Dias, L. V., Cordeiro, M. A., de Sales, R. S., dos Santos, M. M. B. R., Korelo, R. I., &
Vojciechowski, A. S. (2021). Immediate analgesic effect of transcutaneous electrical nerve stimulation (TENS) and interferential current (IFC) on chronic low back pain: Randomised placebo-controlled trial. Journal of Bodywork and Movement Therapies, 27, 181-190.
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(2012). The controversy of managing calf vein thrombosis. Journal of vascular surgery, 55(2), 550-561.
Wilby, M. J., Best, A., Wood, E., Burnside, G., Bedson, E., Short, H., … &
Williamson, P. R. (2021). Microdiscectomy compared with transforaminal epidural steroid injection for persistent radicular pain caused by prolapsed intervertebral disc: the NERVES RCT. Health Technology Assessment (Winchester, England), 25(24), 1.
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