17th June – Marjon clinic. (8 hours) 3 clients
My first client was recovering (9-weeks) from a Fibula stress fracture (Fig.1), which she thought occurred gradually during lockdown when she was using a car park to conduct sprint training on concrete. She had been referred by her GP for an X-ray in week two, when she was having real difficulties walking, but an X-ray did not display anything hence was informed to rest completely for 6-weeks and return for a second X-ray at Derriford. Her results from the second X-ray revealed new bone growth indicating she had indeed suffered a stress fracture. She advised she had started swimming at week 6, and she felt no pain when walking. Through observation and gentle palpation, it was clear she had lost quite a bit of muscle and strength in both legs during this period, and a bit of hardening of leg muscles had occurred, although swimming had clearly assisted her recovery and flexibility during ROM tests. She was a keen runner, and very motivated, which other than restraining such individuals to do further harm to themselves through their exuberance to progress quickly, I personally like working with, as I believe motivation can be contagious, and it certainly leaves me feeling good (feel good factor), in the knowledge I can really assist them to achieve their short-term goals (Hosseini et al., 2021).
Fig 1: Fibula Stress fracture
I advised she could also wear a heat retainer to support and protect her calf muscle whilst walking and offered friendly advice on running shoes and training methods (do not run-on hard surfaces if avoidable when fully fit), which I conduct, which I believe she appreciated. I also conducted a biomechanical check for pronation of the foot rolling inwards, which proved normal. In consultation with client, who advised her GP said she could commence a full recovery programme, this was discussed, initially involving massage, stretching and mobility exercises (gastrocnemius and the soleus muscles), before moving onto strengthening/loading exercises within proprioception (Laskowski et al., 2020). I always try and use examples of positive similar cases, during these consultations, as I know through personal experience, the start of a full recovery programme always seems to go terribly slow, where clients; especially very motivated clients, can get frustrated and try too hard, but when I explain they will be stronger than before if they stick to the programme, this often wins them over.
My second client was an existing female patient suffering from degenerative rheumatoid arthritis, which was predominantly impacting her hands, elbows, and shoulders whom I last saw in March ’21. I started the session with passive/active ROM tests, which from my previous notes, indicated she had better ROM, but only just, and ensured she was not on any blood thinners or similar before conducting some gentle effleurage followed by STR, during which I ensured her pain levels were fine, and also discussed how she was feeling generally and if she had seen any improvements since her last visit (I provided stretching, strengthening exercises to do at home previously). She advised she continued to have good and bad days, but really enjoyed the massage as it eased her pain and made her feel better; she also explained it was awfully expensive to have it privately. I provided further stretching exercises and introduced some light weights (Daste et al., 2021) into the routine for resistance, and explained some weight bearing activities, with muscle/bone impact on her condition (Fig.2) and how she could use household materials (tins or preferably exercise been bags or smaller handheld weights) to conduct a regular regime (Fig. 3). She enjoyed this session and overall, appeared very satisfied. I was happy with the session, and believe it was not only helping her muscles, bones, and joints but also her mental state, as she was so relaxed and happy during and on completion of the session. I am constantly reminded that good communications between the client and practitioner can aid the healing process.
Fig. 2: Weight Bearing – low, moderate, and high impact exercises
Fig 3: Exercises to promote Bone & Muscle Strength
My third client was an online consultation with a 25-year-old female office manager who informed me she was calling from work but had injured the back of her wrist doing a cross fit exercise (wall handstand) the previous day. She explained she was new to the sport, and thinks she just was not ready for the intensity of the session but got carried away! I conducted active ROM with her comparing both hands/wrist/arm movements. She was able to pinpoint the area causing most pain, where I noticed a slight swelling at the back of her wrist, which given injury history and location of pain at the back of her wrist; radial (thumb side), central and Ulnar (little finger side) zones, it looked like a sprain, but I could not be certain. She advised it was tender to touch and although she did not feel like it was broken, it was very painful to move it.
I informed the client to perform PRICE on the site of the injury as soon as the call ended for 10-min every hour, or as able within the office at this juncture, and to get a support brace/bandage for it and rest it as much as possible. I booked her in for a face-to-face appointment the next day after her work where I will apply some wrist resistance to try and determine if there may be any broken bones or similar and pinpoint site of pain (Spielman et al., 2021), which will assist in pinpointing what tendons are involved (Fig.4).
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Fig.4 Common Wrist Pain sites
If I could have done anything differently, I would have asked the client if she had had any previous injuries of her wrist, but I will confirm this at our next consultation, to ensure this is not a repeat injury or perhaps another type of wrist injury. During our discussion, the client advised owing to C-19 her work had laid off staff, and she did not wish to take any days off, as things were not stable, which brought home to me that there were likely many more people at work with injuries they were suffering from but too scared to take time off for. This is something I will look out for, as if clients would rather attend the clinic than their GPs this could cause serious medical problems.
References
Daste, C., Kirren, Q., Akoum, J., Lefèvre-Colau, M. M., Rannou, F., & Nguyen, C.
(2021). Physical activity for osteoarthritis: Efficiency and review of recommandations. Joint Bone Spine, 88(6), 105207.
Hosseini, F., Alavi, N. M., Mohammadi, E., & Sadat, Z. (2021). Scoping review on the concept of patient motivation and practical tools to assess it. Iranian Journal of
Nursing and Midwifery Research, 26(1), 1.
Laskowski, E. R., Newcomer-Aney, K., & Smith, J. (2000). Proprioception. Physical medicine and rehabilitation clinics of North America, 11(2), 323-340.
Spielman, A., Lessard, A. S., & Sankaranarayanan, S. (2021). 14 Wrist Pain After Slip
and Fall. Painful Conditions of the Upper Limb.