Individual with whom I worked with: Mick Smirthwaite
Before my placement:
Aims from today’s placement:
- To become comfortable in the clinic environment
- Establish a good working relationship with my Placement Supervisor
- To observe assessment and treatment of patients who visit the clinic today
- To establish the stage of injury e.g. acute, sub-acute, chronic and the stage of tissue healing
- To try and establish a diagnosis of the injury from the signs & symptoms that each patients presents with
- To understand the rationale for the treatments that Mick applies for each case
- To understand why he chooses a particular modality for treatment
I need to be mindful of:
- Patient confidentiality
- Health & Safety in the clinic environment
Do I need to be aware of particular theories:
- I need to be able to apply my knowledge of anatomy to each case
- Remember the special tests that can be applied to rule out particular conditions
- To understand the soft tissue massage techniques and learn new techniques
The ‘What Ifs’:
- I had thought about the ‘What if…’
I am unable to remember my anatomy
I am unable to remember the stages of the assessment: Subjective, Objective Assessment, Clinical Impression, Plan of Treatment and Therapy.
I am unable to remember the special tests
We all have a fear of making mistakes and of failing but I tried to remind myself that I am going to be in a learning environment under the supervision of an expert. It is a safe environment where I can make mistakes and more importantly, learn from them. To positively receive constructive feedback and to not be afraid to ask questions, even if they may seem silly at first. This is what experiential learning means… to learn from experience.
During my placement:
The private practice is situated in a unit in a local business park. Access to the clinic room is via a door that can only be released open by the receptionist. I arrived about 25 minutes earlier and sat in the reception area, after signing the visitor’s log. After about 10 minutes the receptionist left for the afternoon. I had no way of accessing Mick’s treatment room. I resorted to sending him a private message on my mobile phone to let him know that I had arrived but was unable to come along to the treatment room because the receptionist had left. He came to meet me and let me through the door.
I experienced a mixture of feelings. I was a little anxious because I wasn’t sure what to expect. I was also worried about whether I would be able to answer any of Mick’s questions or be able to apply the skills that I have already acquired, effectively. I was also excited and keen to start my placement. I had thought over the previous days that I would observe Mick during the consultations with clients, witnessing the subjective and objective assessment and observe the subsequent treatment. I did not expect to be involved in the practical application of treatments, only to observe.
After my placement:
On my arrival, Mick informed me that two of his clients had cancelled their appointments which was a little disappointing. For the first hour, Mick and I went through some of the questions on my Checklist A and we discussed my aims and objectives for this placement.
We had a discussion about development of my soft tissue massage skills. I mentioned that I would like to have more experience massaging lower back and hip as I did not feel very confident massaging those areas. I also mentioned that I found massaging larger men more challenging, I would love the opportunity to build my confidence and gain more experience massaging larger men.
There were no appointments scheduled for the second hour so Mick asked me to assess his lower back. He had strained his back when he was hoovering (possible mechanism of injury) on the previous Sunday afternoon (3/7). I was a bit taken aback as I wasn’t expecting to get involved quite so quickly. We went through the subjective assessment. After further discussion he mentioned that he went out running earlier that day. He hadn’t run for a very long time and found it really hard and challenging. His lungs would have worked really hard and so would the other muscles involved in respiration during hard exercise (the other possible mechanism of injury). Mick also mentioned that a felt a pain/ache in the L2, L3 area. During the objective assessment of the Lumbar spine we discovered that there was stiffness on lateral flexion on the left side of the body. There were no issues with lateral flexion on the right side of the body. During flexion of the torso Mick couldn’t achieve the end range (touching toes), which he doesn’t normally find difficult. There were no issues with back extension.
Mick had given me some clues to help me out as I wasn’t completely confident. He suggested that the strained muscle was probably the quadratus lumborum. I wasn’t 100% sure of the muscle’s actions but had a reasonable idea of where in the body it was situated. And because of its location I guessed that it would be involved in lateral flexion, back extension and possibly flexion. Mick encouraged me to palpate the soft tissue in the lower back area and to palpate the spinous process of the Lumbar area. I also palpated the Iliac Crest – remembering that L4 was situated in line with the top of the iliac crest. He did not feel any pain or discomfort during palpation of the vertebrae.
I palpated the left side of his lower back from the Iliac Crest up to the ribs. I found a very tense area and a number trigger points in the quadratus lumborum – just under the ribs, medial to the spine. I performed soft tissue massage applying effleurage, petrissage, deeper effleurage and the Neuromuscular technique to work out the trigger points. One of the trigger points just under the diaphragm was particularly painful and sensitive. I finished the massage with effleurage. I felt quite confident with the techniques that I applied. I enjoy performing massage and take great pride in helping ease client’s aches and pains. Mick gave me some constructive feedback. He told me not to be afraid to apply more pressure when exploring the soft tissue during palpation. He said that the pressure applied during the massage was good.
I realised that I had forgotten to clear the joints above and below during the objective assessment. So I should have cleared the shoulder and the hip joint.
During the third hour, Mick’s first appointment for the afternoon arrived. The client was male in his 60s. He was a roofer. Mechanism of Injury – the client tripped and twisted, whilst carrying a box of his grand children’s toys on the Sunday (72 hours ago). The reason why he twisted during the fall was to avoid hurting his right arm which was in a plaster cast, an injury he acquired during 5-aside football. He felt a pain like a ‘red hot poker’ from his hamstring into the gluteus maximus muscle. When walking upstairs the client led with his right leg because it was painful weight bearing on the left leg. It was also painful whilst sitting and putting body weight on the gluteus maximus muscle, however the client was able to drive a vehicle.
The client removed his trousers and led on the massage table in the prone position. Mick draped a towel over the client leaving the back of the left leg and the buttock exposed. I observed while Mick palpated the hamstring muscles from the knee up to the gluteal fold. There was bruising at the back of the knee, in the middle of the back of the thigh and just under the gluteal fold. I assumed it was the semitendinosus muscle. Mick thought that it could also be the semimembranosus. He explored the tendon under the gluteal fold and allowed me to palpate it too so that I could experience what it felt like. It felt very hard.
The injury was in the inflammation phase – the bleeding had stopped and the inflammation process had started. Inflammation was present in the middle of the hamstring. I was quite excited to see a good example of a hamstring tear. I knew from the signs and symptoms, the pain sensations described by the client and from the appearance of the back of the thigh, that it was a hamstring tear.
Mick applied superficial massage and acupuncture to speed up tissue healing of the injury. He inserted one needle just above the back of the knee, one needle in the middle of the semitendinosus muscle and 3 needles near the origin (tendon at the ischial tuberosity). He asked me to twist the needle in the middle of the semitendinosus, where inflammation was present, to hear the squeaking and note the muscle ‘grabbing’ the needle. Acupuncture causes mild trauma in the muscle and tendon to encourage new blood to get into the tissue with new cells to help speed up the healing process. He brought out an Electroacupuncture Scope and fixed one connector to the needle above the back of the knee and another connector to one of the needles under the gluteal fold. I was going to ask Mick why he was using this particular modality but it then occurred to me that he was applying an electrical pulse into the tissue to generate heat, to improve vasodilation so that the blood could bring new cells, nutrients and remove waste products via the lymphatic system. He applied the acupuncture treatment for 5 minutes. After the treatment he advised the client to rest the leg and keep it straight in order to keep the muscle fibres lengthened, rather than sitting with the leg bent (knee flexed). When I mentioned to Mick the reasons why I believed he was applying this modality of treatment, he confirmed that I was correct in my assumption. After the treatment the bruising had begun to dissipate and the inflammation had reduced. It was wonderful to see an improvement in the client’s range of motion in knee flexion. There was less stiffness and the client walked out of the clinic room without a limp.
He booked the client an appointment for next Wednesday so that I can see the progression of the healing process a week later.
While we were waiting for the last client to arrive, Mick gave me feedback regarding the positioning of my thumbs when applying soft tissue massage techniques, especially NMT. He said it was important to look after my hands to avoid stressing the thumbs and fingers. He demonstrated the position of the thumbs. The advice triggered off memories of aching hands after giving pre- and post- event massages to athletes at local races. I will spend some time looking at YouTube videos of palpation techniques.
In the final hour the next client did not turn up. It is good to be aware of the uncertainty of private practice because sometimes clients do not show up for appointments or cancel last minute due to situations that are out of their control. It also demonstrates quite clearly the financial implications of missed appointments especially if the therapist is not able to fill an empty appointment slot at short notice. Mick said that generally it is usually the clients that have booked an appointment with him for the first time. His regular customers always contact him with plenty of notice if they have to cancel their appointments which allows him to fill the slot with another client.
During the last hour we discussed unusual cases. We also talked about connective tissue because I mentioned that I had started reading a book titled Anatomy Trains (Myers, 2014). I found it interesting because it suggests that all of the muscles and connective tissue in the body are linked and not separate sections as is often taught in anatomy. Mick demonstrated a connective tissue massage technique on my forearm which was really interesting to observe. He knew straight away that I had some issue with the extensor carpi radialis longus and could feel the tension in the muscle tissue. I had been weight training and the muscle was a little stiff and tender as a result. We progressed onto useful reading resources such as ‘Becoming a supple leopard’ (Starrett & Cordoza, 2015) and ‘Fascia in Sport and Movement’ (Avison et al., 2015). Finally we talked about how important it was to maintain a professional online presence especially on the social media site Facebook.
How I felt through-out my placement today:
At the beginning of the placement I was anxious about what I didn’t know. I was a little worried about the level of my anatomy knowledge as I was a little rusty after the summer break. I was also excited at the prospect of learning new techniques and seeing real clients with real injuries.
Evaluate today’s placement activity:
Today’s placement was better and more positive than I could have imagined.
I was a little nervous carrying out the assessment of my Placement Tutor’s injury. My mind went blank when trying to remember the muscles in the lumbar spine region and their actions. My Placement Tutor was very encouraging. I wasn’t very confident when palpating the muscles in the lumbar region as I was a little out of practice. I had performed a number of massages during the summer break but had not practised my palpation skills. I did feel confident performing the soft tissue massage.
I thoroughly enjoyed the assessment and observation of the treatment applied to the client with the torn hamstring injury. I knew the anatomy, was able to diagnose the injury and understood the rationale for the treatment applied and the modality used.
A deeper, analytical and critical approach to today’s experiences:
My lack of confidence in my palpation skills were due to not having practised recently. I will review YouTube videos and practise on my family to gain more confidence.
I am a bit rusty on my anatomy knowledge and will revise the anatomy of the lumbar spine and the hip to ensure that I am able to carry out a thorough subjective and objective assessment.
Draw conclusions – what have I learned from today’s activities and my reflections:
I have learned something new about the different modalities that can be used on injuries in the acute phase of an injury and have seen how effective they are. I am not skilled in acupuncture so I would be unable to apply acupuncture in my practice. I wondered if TENS or low level laser therapy (LLLT) could be used as an alternative to acupuncture. I made a mental note to look at the research literature later.
I have also learned that there are other soft tissue techniques e.g. connective tissue massage.
That there is nothing to be anxious about because even if I make a mistake, I will learn from it in a safe environment. My first day on placement was very motivating, stimulating and very positive.
Action plan – how will I apply what I have learned from today’s activities & my future professional and personal development:
- Practise palpation on family and watch YouTube videos for visual examples of practical application
- Do daily recaps of anatomy
- Update knowledge of the muscles in the lumbar spine, their origins, insertions and actions.
- Continue to read Anatomy Trains to understand more about connective tissue.
- Research the use of TENS and LLLT in reducing pain and inflammation in hamstring tears and promoting tissue healing.
Have any questions arisen from today’s placement that I need to discuss with my Placement Tutor or University Placement Tutor:
I have no questions after today’s placement. I enjoyed the experience and I am looking forward to next week.
Returning to my reflections:
Having re-read my reflection of my first day observing Mick’s practice, I feel that it is an honest reflective account and critical evaluation of that experience. Since the first visit I have revised my anatomy and will never forget where the quadratus lumborum muscle is situated or its actions. I have practised my palpation techniques as a result of having lots of practise in assessing musculoskeletal injuries whilst supporting the BUCS swimming, water polo and futsal teams as well as attending Mick’s practice weekly on external placement.
I also observed that Mick did not follow the formulaic process of assessment of a client’s injury by in-depth subjective and objective assessment. He did ask the client to explain the injury and ask relevant questions but not as thorough as we do in clinic at Marjons. However from the description that the client gave it was quite obvious what the injury was. I had a clear idea of the injury before observing the tissue once the client had positioned himself in the prone position on the couch. The inflammation and hematoma in the middle of the back of the left thigh also gave us a clear indication of the injury. Further exploration by palpation confirmed our initial clinical impression that it was a hamstring tear in the middle of the muscle tissue of the semimembranosus hamstring muscle. I did however wonder whether this was Mick’s normal way of working with his clients. Many of his clients will be regular visitors to his clinic and therefore he will already know them quite well and have an in depth knowledge of their medical and injury history. I made a mental note to consider this in my future visits to Mick’s clinic.
It takes three years to train as an acupuncturist and it is certainly worth considering after I graduate. I wondered however whether TENS and low level laser therapy (LLLT) could be used as an alternative to acupuncture. TENS is inexpensive, non-invasive, portable and easy to use. A review by Almeida and colleagues (2017) suggests that TENS can be used to reduce inflammation in some inflammatory conditions but more research is required. Johnson and colleagues (2015) in their systematic review, found tentative evidence of TENS effectiveness in reducing acute pain when used as a standalone treatment. Machado and colleagues (2012) however found inconclusive evidence that TENS promotes tissue repair. There is some evidence in the research literature that LLLT is effective in skeletal muscle repair in the short term (Alves, Fernandes, Deana, Bussadori, & Mesquita-Ferrari, 2014) and reduces pain (Vinck et al., 2005).
Almeida, T. C. do C., Figueiredo, F. W. dos S., Barbosa Filho, V. C., de Abreu, L. C., Fonseca, F. L. A., & Adami, F. (2017). Effects of transcutaneous electrical nerve stimulation (TENS) on proinflammatory cytokines: Protocol for systematic review. Systematic Reviews, 6(1), 4–11.
Alves, A. N., Fernandes, K. P. S., Deana, A. M., Bussadori, S. K., & Mesquita-Ferrari, R. A. (2014). Effects of low-level laser therapy on skeletal muscle repair: A systematic review. American Journal of Physical Medicine and Rehabilitation, 93(12), 1073–1085.
Avison, J., Chaitow, L., Dennenmoser, S., Eddy, D., Eder, K., Englebert, R. H. H., … Zorn, A. (2015). Fascia in Sport and Movement. (R. Schleip & A. Baker, Eds.). Edinburgh, UK: Handspring Publishing.
Johnson, M. I., Paley, C. A., Howe, T. E., & Sluka, K. A. (2015). Transcutaneous electrical nerve stimulation for acute pain. Cochrane Database of Systematic Reviews, 2015(6).
Machado, A. F. P., Santana, E. F., Tacani, P. M., & Liebano, R. E. (2012). The effects of transcutaneous electrical nerve stimulation on tissue repair: A literature review. Canadian Journal of Plastic Surgery, 20(4), 237–240.
Myers, T. W. (2014). Anatomy Trains: Myofascial Meridians for Manual and Movement Therapists (3rd Ed.). Edinburgh, UK: Churchill Livingstone/Elsevier.
Starrett, K., & Cordoza, G. (2015). Becoming a Supple Leopard (2nd Ed.). Victory Belt Publishing Inc.
Vinck, E., Coorevits, P., Cagnie, B., De Muynck, M., Vanderstraeten, G., & Cambier, D. (2005). Evidence of changes in sural nerve conduction mediated by light emitting diode irradiation. Lasers in Medical Science, 20(1), 35–40.