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 24^th 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

de Sire, A., Agostini, F., Lippi, L., Mangone, M., Marchese, S., Cisari, C., … &

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.

Gabbett, T. J. (2020). How much? How fast? How soon? Three simple concepts for

progressing training loads to minimize injury risk and enhance performance. journal of orthopaedic & sports physical therapy, 50(10), 570-573.

Masuda, E. M., Kistner, R. L., Musikasinthorn, C., Liquido, F., Geling, O., & He, Q.

(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.

Windt, J., Gabbett, T. J., Ferris, D., & Khan, K. M. (2017). Training load–injury

paradox: is greater preseason participation associated with lower in-season injury risk in elite rugby league players?. British journal of sports medicine, 51(8), 645-650.

13^th April. Duration: 6 hours. (2 clients)

My first client was a 34-yr old female was suffering from pain in her elbow. Through questioning and passive/active ROM assessment, I used resistance on her outstretched arm/palm, which reproduced pain on the inside of her elbow, indicating the possibility of medial epicondylitis, a repetitive strain injury (Curti et al., 2021; Wilk et al., 2021).  The patient described the pain got worse when she griped things hard and had got worse over the past 2-weeks, and she now has slight pain on the inside of her elbow when going about her normal daily activities (Fig.1).  The patient worked long hours on a laptop and liked to keep fit in the gym, where she first noticed the niggle after a few sessions.  I also conducted Cozens Test, checking for lateral epicondylalgia, but this test was negative (Karanasios et al., 2021).

She advised she did a repertoire of exercises including wrist curls.  I believed this was a degeneration of the tendon perhaps caused by overloading the tendon too quickly.  I quickly did more research on elbow injuries and noted similar pain can result from an avulsion fracture or medial collateral ligament (MCL) sprain,however, the patients’ symptoms, did not occur immediately, and there was minimal swelling and no bruising, hence although similar pain is felt, I was confident my diagnosis was correct, but of course only an MRI, would be able to detect tendon tears. I am always cognizant not to provide a 100% positive diagnosis to a patient if doubt remains, however, if no further damage could occur through incorrect treatment, I am comfortable giving a professional judgement with the evidence available.

I advised the client to rest the impacted arm/elbow from any activity that caused pain and avoid gripping/carrying heavy objects for a week to see if the pain started to subside.  I provided ice compress for 10-min advising to repeat every hour for a week or as able, and to consider using an elbow brace/ bandage for a few weeks to support it until the pain had subsided.  I also advised after 2-weeks to use heat rather than ice on the wound to promote blood flow, and if her GP authorised, the use of NSAIDs may assist. I finished the session advising the client if after 2-weeks the pain had not gone, a visit to her GP would be advisable, or if pain had gone, she could return where we would assess and if suitable, conduct cross friction massage to the tendon to stimulate healing in conjunction with massaging the muscles of the forearm to reduce tension and improve function.  If I could have done anything differently with this patient, I would have provided more detail reference form when performing weighted exercises including loading, however the patient was very satisfied with her treatment and advice provided.

Fig. 1 Site of pain in medial epicondylitis (Golfer’s elbow

My second online patient was 50-year-old man who explained he had a sore aching shoulder, which had gradually deteriorated over the past 3-weeks or so, was restricting his movement and more painful at night when he lay on it, causing him to wake up. He described the pain as spreading around his shoulder. Through questioning and assessment, I conducted a passive ROM test observing his mechanical movements as best as I could online; minus his shirt on, and how his pain levels felt when moving his neck and arm in different directions (flexion, adduction & internal/external rotation). I informed the patient, I could not conduct all tests online i.e., strength tests/resistance, but got him to apply some resistance on his impacted arm using his good arm, which although not perfect, did assist to identify some muscular areas with pain. Through further research, I was aware there are potential Red Flags with shoulder pain including:  Referred ischaemic cardiac pain Polymyalgia rheumatic etc, hence, decided not to do any more tests online.

The patient advised he did not go to the gym, had not bumped his shoulder, worked in an office, and had never had this pain previously. I was aware, this could be a variety of conditions (impingement syndrome; referred shoulder pain; Glenoid Labrum tear; Surascapylar Neuropathy; Pec Major Tendon inflammation…), however, through questioning, I believed it was more likely to be Frozen shoulder, particularly as the pain was worse at night.  I advised the client, he should visit his GP to have it checked out, but I thought it displayed all the signs of being Frozen shoulder (De La Serna et al., 2021; Hand et al., 2008). Whilst conducting this online assessment, I was acutely aware, a wrong diagnosis with a shoulder injury, could have serious consequences, hence I erred on the side of caution.  I advised the client if it was Frozen shoulder, I believed he may be in the Freezing stage, which may persist for 2-9 months, followed by Stiffening phase (4-12 months), and finally Thawing phase (5-12 months), and regardless, the treatment would be to try to keep the shoulder moving if not too painful, and once he had been to his GP, we could arrange a mobility programme for him at the clinic if pain allowed.  I was not particularly satisfied with this session, as although I believed I had undertaken the correct and safest path for the client, in hindsight, perhaps if I had got him to visit the clinic personally, this would have been a better solution, to offer a more personalised service.

References

Curti, S., Mattioli, S., Bonfiglioli, R., Farioli, A., & Violante, F. S. (2021). Elbow

tendinopathy and occupational biomechanical overload: A systematic review with best-evidence synthesis. Journal of occupational health, 63(1), e12186.

De La Serna, D., Navarro-Ledesma, S., Alayón, F., López, E., & Pruimboom, L.

(2021). A Comprehensive View of Frozen Shoulder: A Mystery Syndrome. Frontiers in Medicine, 8, 638.

Hand, C., Clipsham, K., Rees, J. L., & Carr, A. J. (2008). Long-term outcome of

frozen shoulder. Journal of shoulder and elbow surgery, 17(2), 231-236.

Karanasios, S., Korakakis, V., Moutzouri, M., Drakonaki, E., Koci, K.,

Pantazopoulou, V., … & Gioftsos, G. (2021). Diagnostic accuracy of examination tests for lateral elbow tendinopathy (LET)-a systematic review. Journal of Hand Therapy.

Wilk, K. E., Ellenbecker, T. S., & Macrina, L. C. (2021). Rehabilitation of the

overhead athlete’s elbow. In Elbow Ulnar Collateral Ligament Injury (pp. 327-356). Springer, Cham.

9^th April. Duration:6 hours (4 clients)

My first online client was a 19-year-old female who explained she had redness and itching in her left ear after swimming in Plymouth sound during a charity swim. I asked the client if she had seen her GP yet, and she advised she had not.  I assessed her by looking at her ear for signs of cuts and saw none, nor inflammation on the screen.  I asked the client if she had any pain or had previously suffered from sore ears after swimming and she said no. I also asked if she had used ear buds to clean it out & she advised she had, but only tentatively as it was sore deeper inside.  She advised she had no hearing loss, but it felt a bit ‘bunged up’.  I also asked if she suffered from eczema, asthma, as through reading, I knew these could cause the sufferer to develop Otitis externa quicker, but she advised she did not.  I advised, I thought it may be swimmers’ ear (Fig. 1) known as Otitis externa (Aboutalebian et al., 2021) likely caught owing to dirty water entering her ear drum, and that it should clear up on its own, but she should try using an antibiotic ear drop (if not allergic) in liaison with her local chemist to determine the most suitable ointment.  I also thought it prudent to advise her she should seek GP assistance if her inner/outer ear started to get painful, or the swelling/rash got worse.  If I could do anything differently, post further research, I could have advised her to avoid further swimming whilst suffering, and when she returned to swimming, to try and keep her ears dry (wear a cap or ear plugs) and always immediately shower and dry off with clean towels.

Fig. 1: Swimmers Ear (Otitis externa):

I conducted a passive/active ROM test and advised she must progress gradually, as excessive loading will cause further injury, but provided further stretching exercises emphasising if pain is felt she should stop immediately:

1. Sitting on her heels, gently push down on the heels to feel a stretch the front of the lower leg, holding the stretch for 10 to 20 seconds and repeat 3 times.
2. To increase the stretch, do one leg at a time and lift the knee of the stretching leg.
3. Repeating foot raises in a sitting position to work the tibialis anterior muscle.
4. Various resistance band exercises

I felt this session went very well and advised the client we could conduct another assessment on her injury on a one-to-one session next week.  She agreed to this, and I have booked her in.  Although I was satisfied, with my advice on this call, I felt it would be best to bring her in and conduct a few tests (Star excursion balance; Single limb balance) to really gauge her progress (Karagiannakis et al., 2020).

My next two clients were military returnees, recuperating from lateral meniscus tears, last seen on 26^th March 2021.  Both clients had clearly been diligently conducting their provided exercises and informed me they were going to start conducting physiotherapy rehabilitation with their military counterpart, who had started doing sessions again, hence this would be their final session. I assessed both clients using passive/active ROM and conducted the Y Balance Test (Johnston et al., 2021) and as the clients were extremely keen, I decided to do the test as well as I knew they enjoyed team activities. This worked well.  Test results, were positive, indicating both clients’ mobility and strength were progressing, displaying they had kept to their progressive training schedule (Fig.2).  As the clients would be working with their military physiotherapist, I did not wish to push a further training schedule on them, so conducted some light plyometric exercises, and advised them to inform their military trainer to get in touch with me if he wished to see their Y-Balance Test results, and discuss training provided to date.  They were incredibly happy with this and finished the session on a high.

6^th April. Duration: 4 hours (2 clients)

My first client was a face-to-face emergency appointment. The client had rolled over their ankle during a football game and injured it, however they advised they had a crucial game the next day and needed to carry on regardless of injury. I provided advice against doing such, but the client advised he did not care and would play regardless. As a dancer, I fully understood the mindset of this individual, and tried to reason with him reference potential longer-term outcomes, but he was adamant he would play regardless of treatment.  As a therapist, I believed the best thing I could do was to assist the client to get through the game as safely as possible, otherwise they may inflict further irreparable damage. I conducted a full ankle assessment (Bertrand-Charette et al., 2020) deeming it to be a suspected Anterior Talo-Fibular Ligament (ATFL) sprain (Martin et al., 2021), as the mechanism of injury was inversion and plantar flexion. I carried out observation, passive/active ROM, palpation, and a special test (anterior drawer test). This test went well; I have learned not to apply too much pressure. As suspected, the test proved positive.

I then tested the calcaneus ligament (Fig 1) as that is a common area for injury with suspected ATFL. I used the talar tilt test, which assesses both ATFL and CFL ligaments.  As (Japp et al., 2021), discoursed, the sensitivity and specificity of these tests are best gauged two-five days after injury, hence I am not sure how reliable my test results really, as only one day had lapsed post injury. As the patient was not listening to my supervisor’s or my advice reference not playing, we collectively felt the best thing to do was to strap his ankle providing as much support as able for the game using rigid tape and taping technique allowing the patient to move his foot, but which would assist in preventing him inverting it. I was also aware, compressing the ankle assists to prevent swelling. When taping I felt that I was able to do this process smoothly. I did not tape the heel to ensure he retained movement, and I consciously did not make it too tight, to enable some movement.

I felt given the circumstances, I maintained good communications with the patient and consequently they advised they would return post the game for further treatment! I advised the patient to keep his foot elevated for the next 24 hours as much as possible to help blood flow and reduce swelling. If I could have done anything different, I may have used the cryotherapy (Miranda et al, 2021) to reduce swelling and pain.

I felt this appointment went well, and perhaps in hindsight, we could have been more forceful with him reference not playing, but it was a difficult conversation, as it was noticeably clear he was going to play regardless of advice or treatment provided. I fully understood, but knew he was in a denial stage reference his injury, but perhaps I could have sought assistance from his football team’s therapist, but this would have broached our practitioner and patient confidentiality. I urged him to return after the game for another assessment to see what assistance we could provide.

My second client was a basketball player who had hurt his knee. The patient only experienced pain when exercising. This knowledge proved to be an important aspect when grading the injury. I had initially suspected patella tendinosis (jumpers’ knee) as this is a common basketball players injury, and this injury appeared to be encroaching gradually. My assessment findings were also pointing towards this injury diagnosis. Further ultrasound or MRI exams would assist, but the client advised a lack of money for private diagnosis and waiting times on NHS impacted, the patient was satisfied with my clinical findings at this time. As the patient only experiences pain when exercising, I believe this is currently a grade one injury. Under the circumstances, this is a good, as it means early treatment may prevent further damage. I suggested they stop playing basketball, running, and jumping for the next week, and start gentle stretching and strengthening of the lower leg muscles.

I felt confident when performing the tests and assessment. My assessment indicated they have a weakness in their quadriceps and hamstrings compared to their uninjured side, which is a contributing factor why this injury developed. They explained they had dramatically increased their plyometric training (Correia et al., 2020) over the last 2 weeks, which likely contributed to this injury. I suggested one week initially minus jumping and running, to see if the pain reduced. If successful, a rehabilitation programme will be implemented. I believe I approached this patient’s case very professionally, whilst keeping my supervisor in the loop.  I am currently researching further knee strengthening exercises with Thera Band’s (Karakurt & AĞGÖN, 2018), as when I demonstrated a prone knee flexion exercise with a TheraBand I initially struggled tying it properly, when the patient was watching me so, I practiced directly after they had gone to ensure I did not do this again. The patient was booked in again after two weeks for further assessment and strengthening exercises during which they would mainly rest. I am really looking forward to seeing this patient making good progress.

Fig. 1 Ligaments & Tendons of Foot

References: 

Bertrand-Charette, M., Dambreville, C., Bouyer, L. J., & Roy, J. S. (2020).

Systematic review of motor control and somatosensation assessment tests for the ankle. BMJ Open Sport & Exercise Medicine, 6(1), e000685.

Correia, G. A. F., Freitas Júnior, C. G. D., Lira, H. A. A. D. S., Oliveira, S. F. M. D.,

Santos, W. R. D., Silva, C. K. D. F. B. D., … & Paes, P. P. (2020). The effect of plyometric training on vertical jump performance in young basketball athletes. Journal of Physical Education, 31.

Japp, A. G., Robertson, C., Wright, R. J., Reed, M. J., Robson, A., Alakare, J., … &

Schmidt, H. (2020). Macleod’s clinical diagnosis 2nd edition= Diagnostiikka akuuttilääketieteessä.

Karakurt, S., & AĞGÖN, E. (2018). Effect of dynamic and static strength training

using Thera-Band (R) on elite athletes muscular strength.

Martin, R. L., Davenport, T. E., Fraser, J. J., Sawdon-Bea, J., Carcia, C. R., Carroll,

80. A., … & Carreira, D. (2021). Ankle Stability and Movement Coordination Impairments: Lateral Ankle Ligament Sprains Revision 2021: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health From the Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy, 51(4), CPG1-CPG80.

Miranda, J. P., Silva, W. T., Silva, H. J., Mascarenhas, R. O., & Oliveira, V. C.

(2021). Effectiveness of cryotherapy on pain intensity, swelling, range of motion, function and recurrence in acute ankle sprain: A systematic review of randomized controlled trials. Physical Therapy in Sport.

31^st March. Duration: 6 hours (4 clients)

My first client was a female 52-year-old, suffering from hospital diagnosed degenerative rheumatoid arthritis, predominantly impacting her hands and elbow joints at this stage.  The clients GP advised she needed to be more mobile, hence she had really come for advice and some guidance.  I informed her our aim was to:

• Keep her joints supple.
• reduce pain.

• strengthen her muscles and bones.

Treating an older client was relatively new to me, and as she was not and had never been sporty, I thought it prudent to suggest we try some exercises that she enjoyed, and to set realistic goals, which we could change or adapt as her condition dictated (Levinson et al., 2010). I emphasized the importance of doing these exercises or activities regularly. Having read around this issue (Baillet et al., 2020; Hu et al., 2021; Peçanha et al., 2021), I now realise those afflicted suffer pain almost daily, with intermittent flare ups.

I started the session with passive/active ROM tests followed by STR on the clients’ arms to increase blood flow and stretch muscles, which the client really enjoyed, and during this spoke about things the client enjoyed doing, one of which was swimming/hydrotherapy etc. I STR provided some relief from elbow pain. I advised low-impact exercises were recommended placing less stress on the joints, such as using resistance bands and swimming or cycling, and provided some  practical examples of resistance bands stretches and a URL link to specific exercises for arthritis suffers, which included lifestyle ideas: VERSUS ARTHRITIS . The client was extremely satisfied with the session and advice provided, however, I believe I need to develop my knowledge of arthritis related diseases further, to offer the clients more exercise options applicable to their affliction (Chen et al., 2021).

My next two clients (aged 20-25) were in the latter stages of recovery from lower back injuries caused through conducting dead lifts during weight training. I assessed both clients using passive/active ROM and briefly discussed how the injuries occurred and their training programmes and it appeared they had neglected to strengthen their core. I could have used the Quebec back pain disability scale (Fritz & Irrgang, 2001), but both clients were in latter stages of recovery and moving well, so did not feel it would achieve much as they would likely score incredibly low (Fig. 3).

Both clients were clearly into bodybuilding, hence I did not wish to appear presumptuous, so tentatively discussed the benefits of a progressive training programme (Lloyd et al.,2014), (Fig. 1), and importance of maintaining correct form in daily activities and whilst training to prevent injury and assist their longer-term goals (Faigenbaum et al., 2016; Leysen et al., 2021; Silva et al., 2021; Sørensen et al., 2021; Wilkie et al., 2021). I performed STR on their lower and upper backs and informed them if any pain was evident during this and following exercises to inform me immediately. I wished to exercise their core muscles to increase stability, improve flexibility and strengthen general area, and was aware they may not have conducted these exercises previously, hence tried to add an element of fun into doing them and advised they could be done at home in privacy.

I provided explanation, demonstration and got them to imitate doing (Gafurova & Ruzimbaev, 2021): Bridges, knee to chest stretches, lower back rotational stretches, draw in manoeuvres, pelvic tilts, lying lateral leg lifts, cat stretches, supermans’, seated lower back stretches, partial curls, and resistance band exercises (side-lying: Clam shells; hip abduction; Supine: straight leg raises; hip bridges; cat/cow; Quadruped: Glute Kickbacks; Bird Dog; Plank: Band Pull-Throughs).  To add some weightlifting style exercises, I used a resistance band to do Romanian deadlifts (Fig.2), which I though both clients liked. I ended the session informing both clients that if they experienced lower back pain that was severe or does not go away with gentle stretches and exercise, they should make an appointment with their doctor.  I felt the session went well, but I could have adapted some of the exercises a bit more to match their ‘male’ persona. The use of resistance bands was new to them, and I feel this was successful.

My final client today was a footballer experiencing a slight pain in his upper thigh after taking a penalty kick that day, which he said although not bad, was causing him to take some weight off it when walking. I conducted an assessment asking if they had any previous injury or medical conditions, which he did not.  I conducted observation and palpated the area and noted there was no sign of swelling or heat from the painful area pointed out. Passive/active ROM was conducted (knee bends, resisted muscle tests/hip flexors), which when resistance was applied, he experienced a slight twinge of pain. From the history and assessment, I thought it may be a mild (Grade 1) Rectus femoris tear (Von Fange, 2019; Davis & Rizzone, 2021) but was uncertain as I knew there were four quadricep muscles in the area, however, his history suggested it was more likely to be the Rectus femoris, but I sought a second opinion from the supervisor, who agreed on the diagnosis, advising if it was another quad injury, the initial treatment will be the same, hence I informed the client we would conduct PRICE initially for 72-hours and then reassess the injury.

Fig.1: Youth resistance training guidelines with progression based on each athlete’s resistance training skill competency (RTSC) to perform the desired movements.

Fig. 2: Romanian Deadlift with resistance band

Fig.3: Quebec back pain disability scale

References:

Baillet, A., Payraud, E., Niderprim, V. A., Nissen, M. J., Allenet, B., Francois, P., … &

Gaudin, P. (2009). A dynamic exercise programme to improve patients’ disability in rheumatoid arthritis: a prospective randomized controlled trial. Rheumatology, 48(4), 410-415.

Chen, J. L., Abiri, P., & Tsui, E. (2021). Recent advances in the treatment of juvenile

idiopathic arthritis–associated uveitis. Therapeutic Advances in Ophthalmology, 13, 2515841420984572.

Davis, K., & Rizzone, K. (2021). Quadriceps Tendon Injury. In Common Pediatric

Knee Injuries (pp. 111-124). Springer, Cham.

Faigenbaum, A. D., Lloyd, R. S., MacDonald, J., & Myer, G. D. (2016). Citius, Altius,

Fortius: beneficial effects of resistance training for young athletes: narrative review. British journal of sports medicine, 50(1), 3-7.

Fritz, J. M., & Irrgang, J. J. (2001). A comparison of a modified Oswestry low back

pain disability questionnaire and the Quebec back pain disability scale. Physical therapy, 81(2), 776-788.

Gafurova, M. Y., & Ruzimbaev, M. A. (2021). METHODS OF TEACHING PUPIL

PHYSICAL ACTIVITY IN PHYSICAL EDUCATION CLASSES. Web of Scientist: International Scientific Research Journal, 2(04), 296-305.

Hu, H., Xu, A., Gao, C., Wang, Z., & Wu, X. (2021). The effect of physical exerciseon rheumatoid arthritis: An overview of systematic reviews and meta‐analysis. Journal of Advanced Nursing, 77(2), 506-522.

Levinson, W., Lesser, C. S., & Epstein, R. M. (2010). Developing physician communication skills for patient-centered care. Health affairs, 29(7), 1310-1318.

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Date:10^th November

Location: Marjon Clinic

Duration:3 Hours (3pm-6pm)

Supervisors: Alex & Mike

1^ST hour: This patient was a previous patient who had a stage 3 lateral ankle sprain last time. I went through a full objective and subjective assessment and found that the patient was still not weight baring but was able t move his ankle. My supervisor did another subjective assessment on the patient and asked more specific questions about other possible issues and found possible sciatica and apprehension. I learnt from this that I need to ask more specific questions if things aren’t making sense. I took the patient onto the anti-gravity machine to try and give him the confidence to walk on his foot again. The set-up of the machine went well. I just had to have help from another practitioner to zip the shorts to the machine. The exercises I gave the patient were simple. I demonstrated them well and got him to repeat the movements and give tips on improving technique. This was good because I believe it gave the patient confidence in doing the exercises at home alone. I wish that I had taped his ankle again, but I completely forgot about it. I need to be more careful when things aren’t going well to make sure I still focus to remember what else could help.

2^nd hour: This hour I I had free to write my notes up and research for my next clients. I managed to write up a small rehab plan to send over to the lateral ankle sprain patient. I got advice from my supervisors on seated calf raises which I had never thought of before and adding weight onto his knees in his hand for a progression exercise. I videoed the exercises as well and sent them over. my supervisor checked my technique for the exercises, which all was fine.

3rd hour: I had another previous client who I was treating for lower back pain. My supervisor got another practitioner who is doing a masters to take the objective and subjective assessment again to try and re-diagnose as the treatment for muscular pain with prescribed exercises and stretches was not working to reduce the pain, only the mobility of the patient. I took the notes while the other practitioner did this. She found her flexion was very limited and extension was limited and painful. The supervisor came in asked if we had done extension with overpressure. We hadn’t so she performed this and found that to be very painful. She then explained she believed it to be facet joint pain. She palpated the lower back area and believed it to be central facet joint dysfunction which is I found out caused by ‘Excessive rotation, extension, or flexion of the spine (repeated overuse) Strain of the lumbar facet joint is highest at end-range extension. The supervisor believed the condition to be apprehension as well about getting into a flexed position, so she gave her self-mobilisations at home to improve flexion. I found this interesting as it’s getting patients to get into positions slowly if they’re apprehensive and need more help to get into them, this was a great learning moment for me. The treatment we did was PA L4/L5 lateral mobilisations. The supervisor did the first 60 to show me before I did it. I was able to copy well as I have done this technique before. I found it best using the palm of the hand as that is less pressure than using the thumb, even though it’s harder to be in the right point. I was able to communicate well with my client to find the most appropriate pressure that didn’t cause too much pain. Because the pain was mainly on L5 we were doing the mobilisations on L4, so it wasn’t painful for the client. The supervisor explained to the client what exactly was facet joint dysfunction and how mobilisations can help, she did this using a model spine. I think this was really good for the client and put them in trust of the practitioner and the method of treatment. I will take this on and try and explain to my clients the mechanics if I feel they would be interested.