Thursday 15^th June. Marjon clinic. (5 hours) 2 clients

My first client identified with pain at the back of his knee, with tenderness in his calf muscle just below the back of his knee, which he described as quite severe when it happened during his last game of hockey four days previously.  The client was limping slightly when he walked into the clinic and advised he had used RICE over the past 4-days, and although it had reduced some swelling, the throbbing pain persisted.  Although this sounded like a Grade 1 tear (Fig.1) as there are numerous potential causes of calf strains, I thought it prudent to take my time over this diagnosis.  I conducted palpation on full length of both calf muscles, inclusive of the aponeuroses gastrocnemius, which on the injured leg identified with tenderness in the area he said he felt the acute pain previously, some swelling and thickening present in the medial belly or the musculotendinous junction. At this stage although not certain, I was starting to discount a possible soleus strain as the identified area of pain was outside of the soleus area (Fig.2), however I also conducted a Thompson Test (Schaarup et al., 2021) to try and pinpoint the area of most pain, which also pointed to the gastrocnemius muscle, and during ROM tests when his knee was in full extension the pain was increased (Bojsen-Møller et al., 2004). I also used Trigger points on the gastrocnemius to pinpoint pain (Fig.3):

• The two medial trigger points lie in the medial head of the gastrocnemius, with the upper trigger point found just below the crease of the knee, and the lower trigger point an inch or two below it.
• The two lateral trigger points in the lateral head mirror the positioning of the medial trigger points, except that they lie slightly more distal (towards the foot) by about a half-inch.

I advised the client to refrain from further exercise at this point whilst continuing to rest and provided some very light massage with stretching exercises for the gastrocnemius muscle along with several exercises to work on at home advising if it does not start to feel better within 4-5 days, to visit his GP, who may provide medication or referral for MRI.

I was confident my diagnosis was correct but still feel slightly uncomfortable diagnosing patients with tricky areas minus an MRI diagnosis, I may be wrong, but my confidence levels are definitely increasing around patients, although I occasionally like to refer to my supervisor, notes and internet for support, which I suppose is all adding to my knowledge base. I really feel that my patient handling skills and assessments are progressing and speed of diagnosis increasing although when I look at some of my supervisors, they appear to get through patient much quicker, but having only recently returned to the clinic, I am sure I will get faster.

Fig.1 Grading of Calf Strains

Fig. 2: Gastrocnemius and soleus muscle areas

Fig. 3: Gastrocnemius Trigger Points & Referred Pain

My second client today online and a returnee whom I had previously treated at the clinic for Achilles bursitis caused through overpronation. She advised her heel pain was gradually getting better, and the exercises prescribed; in conjunction with insoles, were working. It was a good feeling knowing my diagnosis and treatment plan were working, which after worrying about my diagnosis abilities, made me feel more confident today. I sometimes feel that back -to-back appointments force one into making decisions, but perhaps it is just my brain going into overload that makes me feel like this in the knowledge that in conjunction with my clinical notes, I must write up my reflections! However, I know deep down that in discussion with my supervisors, I am constantly developing, and every patient I see will be getting a more experienced clinician treating them.

References

Bright, J. M., Fields, K. B., & Draper, R. (2017). Ultrasound diagnosis of calf

injuries. Sports health, 9(4), 352-355.

Schaarup, S. O., Wetke, E., Konradsen, L. A. G., & Calder, J. D. F. (2021). Loss of the knee–ankle coupling and unrecognized elongation in Achilles tendon rupture: effects of differential elongation of the gastrocnemius tendon. Knee Surgery, Sports Traumatology, Arthroscopy, 1-10.

Bojsen-Møller, J., Hansen, P., Aagaard, P., Svantesson, U., Kjaer, M., & Magnusson,

1914. P. (2004). Differential displacement of the human soleus and medial gastrocnemius aponeuroses during isometric plantar flexor contractions in vivo. Journal of applied physiology, 97(5), 1908-1914.

I have never been one to feel comfortable with the unknown. I like the blacks and the whites in life and feel reassured when I have read around a subject adequately to feel I understand it. Grey areas are unsettling for me and leave me with a sense of frustration and, frankly, confusion. This is the root cause of why this week has felt ‘awkward’ and unsettling at times. My handling skills and patient assessments are clearly progressing; I have already completed follow-up appointments alone with my week one patients and successfully managed to assess and treat ‘complex’ diagnoses as my educator affirmed to me in feedback. So why then, do I feel confused, unassured and almost as though I am ‘winging it’ in every appointment? Back to back appointments, with every minute used in the cubicle with the patient, has left me short of time to write up my notes. It also ensures I am scuttling around the department looking far busier than the reality of the three patients I see in a row! Qualified professionals around me, even the newly qualified ‘band 5 rotational physiotherapists’, are seeing upwards of ten patients a day. This isn’t possibly attainable for me, surely? The fact remains, in discussion with my educator, I am constantly developing and every patient is getting a slightly improved version of me each time. My need to know and understand everything, all of the time, is unrealistic and indeed an unnecessary pressure placed on me only by myself! Those I talk to in the department confess they are learning everyday; those who claim to know everything are those that should retire or leave I am told.

My first client was a returning client from another clinician who had diagnosed her with Radiculopathy Facet Dysfunction (Anaya et al., 2021) with a differential diagnosis of shoulder impingement syndrome (Sharma et al., 2021).

I conducted a full assessment; inclusive of ROM, for the cervical, thoracic and shoulders where I identified which body positions were limited and painful and discovered a slight difference from the other clinician’s notes. Through experience, I now know this is not uncommon, as the clinician may have been busy on the day or the patients’ symptoms were not as acute on a given day, but regardless, it reminded me to be as thorough as possible and not to take others notes as the definitive.

From the notes, the patient had deteriorated since her last assessment, however on questioning, she said she felt as though she had improved slightly, hence in this case, I believed that the last clinician may not have recorded the ROM correctly, as the notes explained she had no pain in internal ROM of the shoulder. However, this was the level of movement that caused the greatest pain and had the least strength in.

Through deduction, I decided the most appropriate special test should focus on internal impingement.  I was aware of the Hawkins-Kennedy test, but decided to do a quick search of YouTube to find another test for internal impingement, and found the posterior impingement test, which although it had a weak accuracy scale, may assist (Kamalden et al., 2021).

I was able to perform both tests successfully, despite it being a long time since I last conducted them. I also performed the Neer test for subacromial pain syndrome (SAPS). I had a little bit of trouble turning her arm inwards, but eventually got the correct placement of my hands. Post the assessments, I realised I need to practice conducting more special tests on the shoulder, to enable me to cut down the time with the patient, but more importantly, ensure the correct diagnosis is being made. After the ROM assessment I went onto palpation, which highlighted the patient did not actually have any pain, which indicated it may be mainly deep rather than superficial. I moved onto soft tissue massage focusing on trapezius and rhomboids. The client had a very crunchy feel in the inferior angle of their scapula, subscapularis, and rhomboid muscles. I consequently sought guidance from my supervisor who explained it was connective tissue; dense pockets of muscle, which almost every person has where connective tissue assists in supporting muscles. I believe it is good practice to seek guidance or a second opinion from a more experienced clinician, which also relays to the patient, we are doing everything possible to help them.

During the massage I continually asked (checked) if the pressure was OK. She was very polite and informed me the previous clinician was a bit too hard, and the pressure I was submitting, was much more comfortable. However, she did mention she did not inform the clinician to ease off, so I deduced she may be the type of person who would just accept the pain, so I made sure to not do too much pressure, as she has quite a small frame (Rodrigues et al., 2021).

My next client was online, where I shadowed another clinician with a patient with knee pain. He did a full assessment, which went well as the clinician demonstrated the ROM exercises well and was able to see his movement limitations on the screen. As this was an online assessment, it was chiefly subjective. From observation, I believed it could have been prepatellar bursitis (Samhan et al., 2021), previously commonly known inappropriately as housemaids’ knee. Overall, the patient performed well, and I believe was quite satisfied. If I were to do anything differently, I would probe more to try and narrow down the pain site, however, it was a subjective assessment, which I believe was performed well (Douglas‐Morris et al., 2021).

My last client today was also conducted shadowing a clinician. The patient presented with a possible diagnosis of Medial Epicondylopathy (Finnoff et al., 2021; Hodge & Schroeder, 2021); an overuse of the wrist extensors. It was a useful reminder for me when the clinician referenced TENS machines settings, and consequently I found the advice interesting, but also beneficial, and a good reminder to me that a sports therapist must have a broad range of up-to-date knowledge and experience, when discussing the clients home TENS machine (Park et al., 1984). We discussed acupuncture use as being more inclined to be used for chronic pain relief (Sheikh et al., 2021). For treatment, the clinician also used soft tissue massage utilising a technique called ‘transverse friction massage’, also known as cross-friction and cross-fibre massage, which is a technique that promotes optimal collagen healing by increasing circulation and decreasing collagen cross-linking, thus decreasing the formation of adhesions and scar tissue (Mylonas et al., 2021).

References

Anaya, J. E., Coelho, S. R., Taneja, A. K., Cardoso, F. N., Skaf, A. Y., & Aihara, A. Y.

(2021). Differential diagnosis of facet joint disorders. RadioGraphics, 41(2), 543-558.

Douglas‐Morris, J., Ritchie, H., Willis, C., & Reed, D. (2021). Identification‐Based

Multiple‐Choice Assessments in Anatomy can be as Reliable and Challenging as Their Free‐Response Equivalents. Anatomical Sciences Education.

Finnoff, J. T., & Johnson, W. (2021). Upper limb pain and dysfunction. In Braddom’s

Physical Medicine and Rehabilitation (pp. 715-726). Elsevier

Hodge, C., & Schroeder, J. D. (2021). Medial Epicondyle Apophysitis (Little League

Elbow).

Kamalden, T. F. T., Gasibat, Q., Rafieda, A. E., Sulayman, W. A., Dev, R. D. O.,

Syazwan, A. S., & Wazir, M. R. (2021). Influence of Nonoperative Treatments for Subacromial Shoulder Pain: A Review Article.

Mylonas, K., Angelopoulos, P., Tsepis, E., Billis, E., & Fousekis, K. (2021). Soft-Tissue

Techniques in Sports Injuries Prevention and Rehabilitation. In Recent Advances in Sport Science. IntechOpen.

Park, S. P., Thomas, P. S., Chen, L., Yuan, H. A., Frederiekson, B. E., & Zauder, H.

68. (1984). Transcutaneous electrical nerve stimulation (Tens) for postoperative pain control. Pain, 18, S68.

Rodrigues, M. G. D. R., Pauly, C. B., Thentz, C., Boegli, M., Curtin, F., Luthy, C., … &

Desmeules, J. (2021). Impacts of Touch massage on the experience of patients with chronic pain: A protocol for a mixed method study. Complementary therapies in clinical practice, 43, 101276.

Samhan, L. F., Alfarra, A. H., & Abu-Naser, S. S. (2021). An Expert System for Knee

Problems Diagnosis. International Journal of Academic Information Systems Research (IJAISR), 5(4).

Sharma, S., Hussain, M. E., & Sharma, S. (2021). Effects of exercise therapy plus manual therapy on muscle activity, latency timing and SPADI score in shoulder impingement syndrome. Complementary Therapies in Clinical Practice, 44, 101390.

Sheikh, F., Brandt, N., Vinh, D., & Elon, R. D. (2021). Management of Chronic Pain in Nursing Homes: Navigating Challenges to Improve Person-Centered Care. Journal of the American Medical Directors Association, 22(6), 1199-1205.

17^th 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).

21

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.

06 October – Marjon clinic. (4 hours) 2 clients

My first client today was a male aged 55 years who worked as a self-employed stage installer for the theatre Royal in Plymouth. During our consultation, he advised one year previously (20 Oct 2020) he had extreme low back and a right anterior thigh pain episode. During this period, he saw his GP who referred him for an MRI that he obtained in January 2021, which did not display any noticeable bone issues. He was then referred for physiotherapy at Derriford, which was cancelled (C-19), and when he eventually did attend Derriford (May 2021), he had a lot of trouble parking, and the sessions were noticeably short, hence he decided to try our clinic.

Post subjective assessment via observation via  functional gait assessment (Beninato, & Ludlow, 2016), which appeared normal, and active/passive ROM of legs, neck and entire back area, his thigh pain appeared to have resolved, but he was notably stiff in his neck area, and had highlighted how concerned he was about his stiff back at the end of the day, which he said was not painful, and enquired if this were normal or not, advising he had been given a few exercises by Derriford to do but could I show him different exercises.  I advised him I certainly could and would. During the session, I was aware the client was very tense; perhaps through MRI not identifying anything, as I’m aware patients with painful back injuries, which are extremely difficult to cure, are always looking for the cause, this and the constant stiffness in his back, hence, to calm things down, I advised him MRIs do not always highlight everything, and I asked if he could remember lifting anything last year, which may have brought the pain on, but he said it just gradually happened.  At this stage, my thoughts were leaning towards some type of early degenerative arthritis (osteoarthritis is most common), which was causing his stiffness, or his stiff neck may be impacting on his lower back, which felt very stiff at the end of the day.  I asked him if he had trouble sleeping at night, and he said he often did, hence I advised him it may assist if he tried a cervical, memory foam or feather pillow type, and to try and consciously retain a straight stature during the day; including his head upright where possible, to see if this assisted. The client appeared a bit more talkative after this, perhaps because this was new information, which provided hope, but regardless, it certainly lightened the mood of the consultation.

I conducted Effleurage followed by Petrissage on his neck and back followed by forward, lateral, and sternocleidomastoid neck stretches (Singh et al., 2021), and lower lumber rotation, lower back stretch, latissimus dorsa, cat stretch, lumber rotation and side stretch, advising the client he should try and conduct these stretches at least three times per day (3x 20-min sessions), which should assist in easing his stiff back over the course of 1-4 weeks (Schega et al., 2021). The client advised his lower back felt relaxed at this point, which he was incredibly happy about. I also discussed the benefits of stretching daily for everyone (Chilibeck, 2021), highlighting static, dynamic, Proprioceptive Neuromuscular Facilitation (PNF) and Muscle Energy Techniques (METs).  I finished the session advising the client he could return in 2-weeks if he wished (use booking system), where we would re-assess his condition, which he appeared grateful for.  This session started awkwardly from a communicative perspective but ended positively, although I am still not 100% certain I have pinpointed the real cause of his stiffness, however, as the client appeared to get some relief from the treatment and advice provided, at this stage I am satisfied I did all I could.

My final client today was at stage 3 recovery from a groin strain, caused playing pro professional football.  Progressive stretches and weighting exercises were performed in sets inclusive of straight leg standing groin stretch; seated groin stretch; hip flexor stretches and strengthening exercises via progressively stronger resistance bands; light kicking motions and squeezing various sized balls between legs; eccentric adduction, straight leg raises, hip adduction using chair and unsupported increasing difficulty and core strength exercises.  The client was progressing well minus any pain, but still needed more strength in his abductor muscles, hence I was careful not to push his recovery via too many loads hence used various Eccentric exercises using cables.  I was satisfied with this client’s progression, and having dealt with several groin strains previously, was acutely aware, too much loading at this stage was very dangerous, hence constantly advised the client to take things very slowly to enable us to move onto functional exercises in a week or so.  I am always slightly surprised when football players advise me, they rarely conduct specific abductor exercises for the sport, as through my limited experience treating such, appears to be the main cause of most groin injuries in football (Esteve et al., 2021).

References

Beninato, M., & Ludlow, L. H. (2016). The functional gait assessment in older adults: validation through Rasch modeling. Physical therapy, 96(4), 456-468.

Chilibeck, P. D. (2021). Response to “Commentary on: Stretching is Superior to Brisk

Walking for Reducing Blood Pressure in People With High–Normal Blood Pressure or Stage I Hypertension”. Journal of Physical Activity and Health, 18(4), 347-347.

Esteve, E., Casals, M., Saez, M., Rathleff, M. S., Clausen, M. B., Vicens-Bordas, J.,

… & Thorborg, K. (2021). Past-season, pre-season and in-season risk assessment of groin problems in male football players: a prospective full-season study. British Journal of Sports Medicine.

Schega, L., Kaps, B., Broscheid, K. C., Bielitzki, R., Behrens, M., Meiler, K., … &

Franke, J. (2021). Effects of a multimodal exercise intervention on physical and cognitive functions in patients with chronic low back pain (MultiMove): study protocol for a randomized controlled trial. BMC geriatrics, 21(1), 1-13.

Singh, R., Jagga, V., & Kaur, S. (2021). Effect of Combining Stretching and Strengthening Exercises of Neck Muscles in Forward Head Posture among Desk Job Operators. Asian Journal of Orthopaedic Research, 1-5.

13 October – Marjon clinic. (4 hours) 2 clients

My first client today was a 61-year-old male who had hurt the left side of his lower back whilst digging his garden using a heavy pick, advising it was very stiff and a bit tender.  He advised he also had arthritis. He described his back was more painful when he tried to bend down to pick things up. He had been diagnosed with chronic back pain via a herniated disc (L4/5) 13-years ago (Fig.1), which was treated conservatively, taking approximately 1.5 years to heal, and had since had many smaller aches/pains in his back region. He still liked to walk to try and keep fit and advised his back issues were down to previously being in the armed forces where he often carried heavy back packs, parachuted, and after leaving the military (41yrs old), generally kept fit via runs up until his back injury, which now prohibited him doing any real fitness activities.  He said he tried to keep active, and massage had previously assisted the healing process, along with stretching and strengthening exercises. He advised he did not go to his GP unless it was bad.  He took ibuprofen daily.

Fig. 1 Herniated Disc

Post assessment via functional gait assessment (Kuligowski & Sipko, 2021), and passive/active ROM palpation, I noted he was taking smaller strides than normal, which he attributed to being painful if he strides out, and he was notably stiff in his neck area and tender around the lower lumber area, which was the epicentre of his pain but had no signs of sciatica. During the session.  It was clear this elder client was very pro-active, knowledgeable on his injury, and was merely looking for some support via massage to speed up his recovery however, regardless, I informed him if his injury deteriorated, he should visit his GP.

Given clients history, assessment results and discussion, I was satisfied his injury appeared to be symptomatic of his chronic back pain, associated with his L4/5 discs, which had likely been aggravated by the swinging action of the heavy pick (he was right-handed).

I conducted Effleurage followed by Petrissage on his neck and back followed by forward, lateral, and sternocleidomastoid neck stretches (Singh et al., 2021), and lower lumber rotation, lower back stretch, latissimus dorsa, cat stretch, lumber rotation and side stretch, advising the client he should try and conduct these stretches at least three times per day (3x 20-min sessions), which should assist in easing his stiff back over the course of 1-4 weeks (Schega et al., 2021). The client advised his lower back felt relaxed at this point, which he was incredibly happy about. I also discussed the benefits of stretching daily for everyone (Chilibeck, 2021), highlighting static, dynamic, Proprioceptive Neuromuscular Facilitation (PNF) and Muscle Energy Techniques (METs).  I finished the session advising the client he could return in 2-weeks if he wished (use booking system), where we would re-assess his condition, which he appeared grateful for.  This session reminded me that although we can offer a certain amount of relief to patients, some unfortunately will always suffer, and minus being proactive could deteriorate further heralding further lack of mobility.

This session invoked a need on my part to understand more about what resilience is, and whether it is learnable or inherent in a person’s personality.  As (Chiu et al., 2021) investigated, individuals with spinal cord injuries must be assessed frequently to assess the individual’s resilience level and characteristics of resilience on an ongoing basis. They achieved such via the Connor-Davidson Resilience Scale (CD-RISC), Connor & Davidson (2003).  They broadly defined resilience as having the capacity to deal with significant disruption, change or adversity. Common traits associated with resilience were hardiness, hope, self-confidence, resourcefulness, optimism flexibility and emotional intelligence (McDonald et al., p.134) who discussed how training programs within the workplace could be established to teach people these skills, although I personally do not believe this would be a good idea, as it could not possibly address everyone’s personal issues, and could actually invoke further issues, but perhaps post evaluation, it may benefit some people.

A plan to work on my own resilience in preparation for a future role as a practicing sports therapist to ensure I have positive patterns embedded in my practice and everyday life. This would include engaging in habits of mindfulness on a day-to-day basis (Schuman-Olivier et al., 2020).

My final client today was a returnee 50-year-old male who was recovering from a mild (grade 1) anterior cruciate ligament sprain.  The client had attended three times to date but did not appear to be following his prescribed rehabilitation programme as post re-assessment, he had not progressed as well as he should have.  The client was visible obese for his body frame, and very friendly, but always needed to be directed to conduct the exercises, and although he responded and worked well in the clinic, I had reservations as to his advice he was doing the prescribed exercises (flexion/extension; heel slides; hamstring, groin stretches using resistance band, Isometric quadriceps exercises and proprioception exercises) at home.

I often encounter patients who discuss a wish to change to their lifestyles, but have noted other than discussions, after months of therapy, they have not progressed to put their plans into action. This is especially true of patients who have trouble controlling their weight. For many patients, learning how to make healthy choices and undertake exercise can be empowering, but also challenging. There is so much to learn about patient care, and I am aware I still have a lot to learn about human behaviour, but it has increased my openness to learn more to be able to provide better patient education, especially within the informal settings of treatment and massage. I always try to approach patients in an open and friendly manner, and work with what interests and concerns them, which has to date been effective in changing some, but not many patients’ behaviours. I have found informal exchanges of ideas can help patients choose healthier activities. I believe I have also improved my knowledge of educational techniques, such as motivational interviewing (DeVargas & Stormshak, 2020), which I will continue to research further and use within future clinical practice and attend educational meetings and lectures to further develop these skills. I think having a better knowledge of the treatments for obesity, will assist me to help some patients. It is abundantly clear to me that as a sports therapist, you must remain open to learning to improve one’s effectiveness, to provide patients with the best opportunity to achieve healthy lifestyles, which will aid their recovery from injury, but I am also acutely aware, there is a thin line between giving advice and preaching, which can have a negative impact on recovery.

References

Chiu, C., Brooks, J., Jones, A., Wilcher, K., Shen, S., Driver, S., & Krause, J. (2021).

Resilient Coping Types in People With Spinal Cord Injury: Latent Class Analysis. Rehabilitation Counseling Bulletin, 0034355221990736.

Connor, K. M., & Davidson, J. R. (2003). Development of a new resilience scale: The

Connor‐Davidson resilience scale (CD‐RISC). Depression and anxiety, 18(2), 76-82.

DeVargas, E. C., & Stormshak, E. A. (2020). Motivational interviewing skills as predictors of change in emerging adult risk behavior. Professional Psychology: Research and Practice, 51(1), 16.

Kuligowski, T., & Sipko, T. (2021). Lumbopelvic Biomechanics in Patients with Lumbar Disc Herniation—Prospective Cohort Study. Symmetry, 13(4), 602

McDonald, G., Jackson, D., Wilkes, L., & Vickers, M. (2013). Personal resilience in nurses and midwives: Effects of a work-based educational intervention. Contemporary Nurse: A Journal for the Australian Nursing Profession, 45(1), 134-143.

Schuman-Olivier, Z., Trombka, M., Lovas, D. A., Brewer, J. A., Vago, D. R., Gawande,

R., … & Fulwiler, C. (2020). Mindfulness and Behavior Change. Harvard review of psychiatry, 28(6), 371.

20^th October Duration: 5 Hours (3-clients).

My first client today was a returnee in stage four recovery from an Achilles tendonitis (Cramer et al., 2021) whom I last saw at the end of March 2021 (C-19 interrupted rehabilitation). He advised he had attended two sessions at the clinic during this period with other practitioners and was actively participating on the Hakan Alfredson’s heel drop protocol (Gatz et al., 2020).

Post re-assessment, the client had progressed well and was in the functional stage of rehabilitation with no visual signs or pain noted during ROM or on the Achilles Pain Questionnaire (Robinson et al., 2001), (Fig. 1).

Fig. 1 Achilles Pain Questionnaire

Prior to commencing eccentric loading strengthening exercises (Gastrocnemius & Soleus), balance, proprioception and plyometrics, I conducted STR (Maffulli et al., 2017) noting there was no swelling or tenderness. It never ceases to amaze me how long it takes to repair Achilles Tendon injuries using surgical or conservative treatments, but as it is the strongest tendon in the human body, perhaps it’s not surprising. However, as conservative treatment debatably remains the preferred option; less complications, (She et al., 2021), with various factors hinging on the patient’s situation and suitability, I have found aside from the physical factors involved, the patient’s motivation levels often appear to dictate recovery times if no medical reasoning is involved (Hosseini et al., 2021; Toale et al. 2021). From personal experience of this injury, I know how difficult it is to remain motivated when injured, particularly if being physically fit is connected to your income stream or career potential, which from personal experience has been the case in many of my patients, as Ananat & Gassman‐Pines (2021) elucidated.

My second client was online who described herself as a new but enthusiastic weekend stand-up paddleboarding (SUP) enthusiast, with pain in her shoulder. She described the pain as a dull ache, which gradually came on when paddling, which got stiff and more painful afterwards, but often calmed down after a few hours. She advised she had not sought other treatment from a GP or physio, had not suffered shoulder pain previously and was not on anti-inflammatory medication, I conducted a subjective online active and assisted ROM assessment of her shoulders, which revealed the pain was more evident when moving the shoulder. I had performed similar online shoulder examinations previously and asked if she felt any tingling in her hands/fingers to try and rule out referred pain, which she did not. I knew the complexities of gauging and recording exact degrees of movement using visual means only was difficult online, and how clear positive communications was essential to get the best possible history. I suspected she may be suffering from shoulder tendinopathy or some form of impingement, hence advised she use PRICE tonight and come into the clinic for a 1:1 assessment, where I could conduct palpation and further tests (tin; Neer; Hawkins; Gerbers lift-off; Drop Arm; Apprehension; Crank & Yergasons tests) to try and identify and pinpoint the location of most pain. I booked the client in for a face-to-face appointment the next day.

I had not dealt with a suspected shoulder injury potentially caused through paddle boarding, hence did some further investigation later, which highlighted shoulder impingement injuries were common in the sport.  With this knowledge, I’ll feel a bit more knowledgeable when speaking/examining the client tomorrow.  Through patient 1:1s, I know having some knowledge of the sports or activity they are interested in often breaks the ice allowing greater depth of communications to occur, which can often provide further information, which may be relevant to assisting the patients healing process (Mack et al., 2021).

My third and final client today was an older lady (80+) who had taken a fall 1-month previously injuring her right hip, which was x-rayed and found to have no broken bones.  Her GP prescribed ant-inflammatory and initially pain killers, which were then discontinued from her prescription. Post questioning, and conducting ROM and observation of her gait (she currently used a walking stick), I couldn’t see any bruising or swelling when compared to her able hip however, she was limping, but her gait appeared normal otherwise (no overpronation) and during palpation had pain when the outside of her hip was pressed, but she advised it did not radiate down the thigh, hence this may have indicated

During my clinical experiences, I have been privileged to witness and participate in multidisciplinary team efforts and have also had the opportunity to work with different healthcare professionals, which has really broadened my experiences and skill base, I have always felt part of the team within the clinic, and as I have gained in practical experience, felt I was making a valuable contribution.  Even when some patients have been challenging, the team’s inclusiveness and supportiveness helped me to push forward. I have learnt that you must ask questions when unsure, and if you display enthusiasm and eagerness, the team will be there for you if required. I have also learned that patients can also be a great source of learning (lifelong learning).

References

Castañeda-Babarro, A., Calleja-González, J., Viribay, A., Fernández-Lázaro, D.,

León-Guereño, P., & Mielgo-Ayuso, J. (2021). Relationship between training factors and injuries in stand-up paddleboarding athletes. International journal of environmental research and public health, 18(3), 880.

Furness, J., Olorunnife, O., Schram, B., Climstein, M., & Hing, W. (2017).

Epidemiology of injuries in stand-up paddle boarding. Orthopaedic journal of sports medicine, 5(6), 2325967117710759.

Mack, R., Breckon, J., Butt, J., & Maynard, I. (2021). Practitioners’ use of

motivational interviewing in sport: A qualitative enquiry. The Sport Psychologist, 1(aop), 1-11.